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Purpose: This study provides an insight on the extent of muscular variability at the suprascapular notch and elaborates on its anatomical interference in suprascapular nerve arthroscopic decompression procedures. Methods: The suprascapular notch was dissected and its muscular topography was observed in 115 cadaveric specimens. High resolution imaging of the suprascapular notch was captured by a handheld digital microscope (Q-scope). The supraspinatus and subscapularis muscles were traced as they course at the suprascapular notch vicinity. The omohyoid muscle attachment onto the suprascapular ligament was measured. A scoping review and meta-analysis were done to investigate the observed rare muscular variants. Results: In 3.48%, the suprascapular notch anterior surface was fully covered by the subscapularis muscle. The omohyoid muscle inserted onto the suprascapular ligament in 31.25% and extended up to 3/4th of the suprascapular ligament length in 2.61%. Two rare variant muscles were encountered: subclavius posticus muscle and a newly reported "coracoscapularis muscle". Conclusions: Four categories of muscles with topographical relationship to the suprascapular notch and its arthroscopic feasibility have been classified: (1) constant muscles not intervening with the suprascapular notch space – supraspinatus muscle; (2) constant muscles with variable positions that can intervene with the suprascapular notch space – subscapularis muscle; (3) constant muscles with variable positions that can intervene with the surgical approach – omohyoid muscle; (4) variable muscles intervening with the suprascapular notch space and surgical approach – subclavius posticus and coracoscapularis muscles. This study elucidates the necessity to assess/secure the omohyoid muscle attachment onto the suprascapular ligament in suprascapular nerve decompression ligamentectomy. Level of evidence: V Basic Science Research. [ABSTRACT FROM AUTHOR]

Objective: To explore the changes in the white matter microstructure of the ascending pain conduction pathways in patients with chronic neck and shoulder pain (CNSP) using combined brain and spinal cord diffusion tensor imaging techniques, and to assess its correlation with clinical indicators and cognitive functions. Materials and methods: A 3.0T MRI scanner was used to perform combined brain and spinal cord diffusion tensor imaging scans on 31 CNSP patients and 24 healthy controls (HCs), extracting the spinothalamic tract (STT) and quantitatively analyzing the fractional anisotropy (FA) and mean diffusivity (MD) which reflect the microstructural integrity of nerve fibers. Additionally, these differences were subjected to partial correlation analysis in relation to Visual Analog Scale (VAS) scores, duration of pain, Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS). Results: Compared to HCs, CNSP patients showed decreased mean FA values and increased mean MD values in bilateral intracranial STT compared to the HC group, but two-sample t -test results indicated no statistically significant differences (p > 0.05). FA values of the left STT (C2 segment, C5 segment) and right STT (C1 segment, C2 segment) were significantly decreased in bilateral cervical STTs of CNSP patients; MD values of the left STT (C1 segment, C2 segment, C5 segment) and right STT (C1 segment, C5 segment) were significantly increased (p < 0.05). Partial correlation analysis results showed that FA values of STT in CNSP patients were negatively correlated with VAS scores, duration of pain, SAS scores, and SDS scores, while MD values were positively correlated with VAS scores and duration of pain (Bonferroni p < 0.05). Conclusion: This research identified that patients with CNSP exhibited reduced mean FA and increased mean MD in the bilateral intracranial STT, although these differences were not statistically significant (p > 0.05). Conversely, significant abnormalities were observed in specific segments of the bilateral cervical STT (p < 0.05), which were also correlated with variations in pain intensity, illness duration, and levels of anxiety and depression. These findings contribute a novel neuroimaging perspective to the evaluation and elucidation of the pathophysiological mechanisms underlying chronic pain in the ascending conduction pathways. [ABSTRACT FROM AUTHOR]

Parsonage-Turner syndrome (PTS) and ankylosing spondylitis (AS) are distinct clinical entities with unique pathogenic mechanisms. The coexistence of these conditions in a single patient is rare and presents diagnostic and management challenges especially in adolescent patient. In this case report, we present a unique and intriguing case of an 18-year-old boy presented with acute onset shoulder pain and weakness, consistent with PTS. However, further evaluation revealed additional features suggestive of AS, including chronic low back pain and morning stiffness. Diagnostic workup, including imaging studies and laboratory investigations, confirmed the presence of both PTS and AS. The management approach involved a multidisciplinary approach, including physical therapy, analgesics, and corticosteroids. This case report underscores the significance of considering the possibility of concurrent PTS and AS in patients presenting with atypical symptoms or overlapping clinical features. Clinicians should be aware of the potential overlap between PTS and AS to guide optimal treatment strategies and improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Resistance exercise is recommended as the first line of treatment for rotator cuff related shoulder pain (RCRSP), but with conflicting evidence supporting the superiority of specific prescription parameters. Particularly, the role of pain-related prescription parameters remains poorly understood, despite their wide clinical application and potential impact on treatment outcomes. This review aims to investigate how pain-related prescription parameters, such as pain allowance and intensity limits, are reported, described, and applied in clinical trials assessing resistance exercise interventions for RCRSP. Methods: Guided by PRISMA-ScR, this scoping review followed a comprehensive and systematic search in MEDLINE (Ovid), MEDLINE (EMBASE), Central (Cochrane), PEDro and CINAHL (EBSCO). Two authors independently performed title and abstract screening, and full text screening on eligible records. Randomized clinical trials (RCTs) published in English between 2018 and 2023, applying resistance exercise for RCRSP were included. Both quantitative and qualitative approaches to data analysis were conducted. Results: The literature search identified 7500 records, of which 4588 titles and abstracts were screened after duplicate removal. Altogether, 304 full texts were screened leaving a total of 86 records in the final analysis. Fifty-eight (67%) studies did not mention the use of any pain-related prescription parameters, resulting in data extraction from the 28 remaining studies. Applied parameters were widely heterogenic, but three categories of pain allowance styles were identified and categorized into "yes", "no" or "ambiguous". These categories were commonly guided by specific Numerical Rating Scale (NRS)/Visual Analog Scale (VAS) limits or individual pain tolerance, used for pain monitoring and exercise progression. Citations and/or justifications for the chosen pain-related prescription parameters were reported by 10 (36%) studies, in which 5 main themes for justifications, and 3 key papers for the citations were identified. Conclusion: This review reveals substantial reporting deficiencies regarding pain-related prescription parameters in RCTs addressing RCRSP with resistance exercise. The identified parameters varied widely, reflecting a lack of consensus and evidence-based guidance in the literature and in a clinical setting. To advance our understanding on the role of pain-related prescription parameters, more consistent reporting of these parameters in future research is warranted. Trial registration: Published on the Open Science Framework 28.02.24: osf.io/a52kn. [ABSTRACT FROM AUTHOR]

The rare occurrence of diffuse large B-cell lymphoma (DLBCL) limited to the spleen presents difficulties in diagnosis. A case report details a patient whose initial symptoms were neck and shoulder pain, subsequently diagnosed as spontaneous spleen rupture, a rare complication of primary splenic lymphoma. Following a splenectomy, the patient was confirmed to have primary splenic DLBCL and made a good postoperative recovery. This report highlights the diagnostic dilemmas in atypical presentations, where neck and shoulder pain may be the only early sign of a neglected spleen rupture, lacking typical symptoms of the underlying disease. In cases of patients who are not stable, the recommended first imaging method is a focused assessment using sonography for trauma (FAST), as CT scans have a high level of sensitivity. Treatment is determined by hemodynamic status, with conservative management for stable patients and surgical intervention for unstable patients. The importance of recognizing spontaneous spleen rupture as a critical yet uncommon possibility in acute abdominal cases, especially in instances of primary splenic DLBCL, is emphasized in the report. [ABSTRACT FROM AUTHOR]

Background/Objectives: Many patients with neck pain have upper limb disorders, and prolonged use of computers at work commonly induces neck/shoulder pain. The purpose of this study was to investigate the psychometric properties of the Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) in patients with neck pain. Methods: A total of 189 patients with neck pain were included in acceptability, reliability, validity, and responsiveness studies. The floor and ceiling effects were used for assessing acceptability. The internal reliability and test–retest reliability were used for assessing reliabilities. The construct validities (convergent/divergent validity and exploratory/confirmatory factor analyses) were used for assessing validity. The effect size (ES) and standardized response mean (SRM) were used for assessing responsiveness. Results: The QuickDASH had a slight floor effect (16.4%). For reliability, the internal consistency (Cα= 0.945) and test–retest reliability (ICC = 0.98; SEM = 3.17, and MDC = 8.79) were excellent. For validity, the convergent and divergent validities were satisfactory. Exploratory factor analysis revealed two factors of the QuickDASH (function factor and symptom factor), and confirmatory factor analysis confirmed the two-factor model. Responsiveness was supported by the high ES (0.85) and SRM (0.82). Conclusions: The QuickDASH is a reliable, valid, and responsive instrument for assessing upper limb disorders in patients with neck pain. [ABSTRACT FROM AUTHOR]

Background/Objectives: Due to rigidity, musculoskeletal pain is more common in people with Parkinson's disease (PD) compared with age-matched older adults, and the shoulder is one of the body parts that is most involved. In the literature, there is no clear standard for the treatment of shoulder pain in people with PD. This clinical trial study aimed to evaluate the effectiveness of physiotherapy treatment for people with PD with painful shoulders. Methods: The main goals were improvements in pain intensity, balance, quality of life (QoL), and activities of daily living (ADL), evaluated with the Parkinson's Disease Questionnaire 39 (PDQ-39), Berg Balance Scale (BBS), Community Integration Questionnaire (CIQ-R), 12-Item Short-Form Survey (SF-12), Disabilities of the Arm, Shoulder, and Hand (DASH) scale, and Numeric Pain Rating Scale (NPRS). Also, the evaluation comprised range of motion (ROM) evaluation with a goniometer and the Medical Research Council (MRC) scale. The inclusion criteria of this study were a diagnosis of PD associated with shoulder pain, and a stage of disease of 1–2 on the Hoehn and Yahr scale. Results: The sample comprised 16 participants; the mean age of the participants was 72. Through feedback collected from the individuals participating in this study, it emerged that the rehabilitation approach specifically designed for individuals suffering from shoulder pain associated with Parkinson's disease produced remarkable results. Conclusions: These results were confirmed by a series of statistically significant data, which showed significant improvements in several areas: joint mobility, muscle strength, motor coordination, the ability to perform daily activities, emotional state, pain reduction, QoL improvement, and balance in both dynamic and static conditions. [ABSTRACT FROM AUTHOR]

Purpose: To observe the clinical efficacy and safety of arthroscopic single-row modified Mason-Allen(mMA) suture technique in repairing delaminated rotator cuff tears (RCTs). Methods: According to the inclusion and exclusion criteria, a total of 65 selected cases were treated with mMA by a senior physician. Outpatient follow-up visits were conducted at 1.5 months, 3 months, 6 months, and longer after treatment. The postoperative shoulder range of motion (ROM), Constant Murely score (CS), and UCLA shoulder joint score were evaluated by the same examiner. After the follow-up, the data will be summarized and finally subjected to statistical analysis (Fig. 1). Results: Collected 65 patients with delaminated RCTs repaired using arthroscopic modified Mason-Allen suture technique from May 2022 to June 2023. Three were lost to follow-up, leaving 62 patients who were included in the study analysis, including 21 males and 41 females; age ranged from 50 to 81 years old, with a median age of 65 years old; 34 cases in the left shoulder and 28 cases in the right shoulder; 30 cases with a history of trauma and 32 cases with no obvious history of trauma; According to the Cofield classification of RCTs, all were delaminated tears of the rotator cuff. We recorded changes in shoulder range of motion (ROM) and functional ratings for at least 6 months (6 months to 18 months, average 10 months) postoperatively. Shoulder anteflexion improved from 98.06 ± 11.28° to 172.26 ± 6.63° (P = 0.028), abduction improved from 69.68°±18.55° to 160.97 ± 9.53° (P = 0.006), internal rotation improved from 14.52°±10.35° to 45.81 ± 4.97° (P = 0.007), and external rotation improved from 22.42°±8.62°to 51.29 ± 6.14° (P = 0.027); CS preoperative 49.08 ± 4.91and at the last follow-up 97.89 ± 1.62 (P = 0.043); and UCLA shoulder score, preoperative 15.73 ± 2.60 and at the last follow-up 33.85 ± 0.15 (P = 0.044). 3 cases developed adhesive capsulitis symptoms due to inactive rehabilitation activities after the operation, and the symptoms disappeared after standard rehabilitation training (no secondary operation). All patients had no problems such as rotator cuff tearing and anchor removal. Conclusion: The use of mMA suture technique to repair rotator cuff delamination tears can effectively relieve shoulder pain, improve shoulder function, and have fewer complications. [ABSTRACT FROM AUTHOR]

Objectives. Among cleaners, lower back pain (LBP) and neck/shoulder pain (NSP) are prevalent musculoskeletal disorders (MSDs). Despite their high occurrence, the underlying causes of LBP and NSP in this population remain largely unknown, suggesting a multifactorial aetiology. This study aims to assess the association between various lifestyle, physical and psychosocial factors with LBP and NSP in professional cleaners. Methods. The study included cleaners from the Danish Work Environment and Health study 2012–2018 with a total of 1042 responses. The cleaners filled in a questionnaire about their work environment, lifestyle and health. Associations between a range of work and lifestyle factors (predictors) with LBP and NSP (outcome) were estimated using general linear models. Results. When controlling for various confounders, cleaners experiencing high physical exertion during work showed higher LBP and NSP compared with those experiencing low and moderate physical exertion (p < 0.0001). Low recognition from management was also associated with higher LBP and NSP (p < 0.05). Several factors did not reach statistical significance: smoking, leisure physical activity, influence at work and support from colleagues. Conclusion. This cross-sectional study showed that obesity, high physical exertion during work and low recognition from management were associated with higher LBP and NSP. [ABSTRACT FROM AUTHOR]

Objective: Unusual clinical course Background: Guillain-Barré syndrome (GBS) commonly presents with motor weakness and neurological symptoms and signs that include loss of tendon reflexes. However, patients with GBS also experience nerve pain (radicular pain) and deep muscle pain. This report is of a 73-year-old man presenting with shoulder muscle pain and a diagnosis of Guillain-Barré syndrome. Case Report: A 73-year-old man initially sought medical attention for severe left shoulder muscle pain. One week prior, he had experienced a cold and diarrhea, which improved with over-the-counter medication. Physical examination revealed normal shoulder joint motion without swelling or stiffness. Cervical spine magnetic resonance imaging (MRI) revealed osteophytes and disc protrusions from C3/4 to C6/7, leading to an initial diagnosis of cervical spondylosis. Two days later, he developed progressive numbness and weakness in both upper limbs. Upon hospital admission, further evaluation revealed partial cranial nerve dysfunction, elevated cerebrospinal fluid (CSF) protein levels without pleocytosis, and peripheral nerve damage on electromyography (EMG). GM1 antibody was positive, confirming GBS. Treatment with intravenous immunoglobulin (IVIG), gabapentin for pain management, and acupuncture targeting pain and limb symptoms resulted in the complete recovery of pain and limb function within a short period. Conclusions: This report shows that deep muscle pain can be a symptom of Guillain-Barré syndrome. Recognizing such atypical presentations is crucial for timely diagnosis and effective management. This case provides a clinical basis for the diagnosis of atypical GBS and offers insights into pain management in GBS. [ABSTRACT FROM AUTHOR]

Background: Humeral shaft fractures account for 1–3% of all bone fractures. Conservative treatment often leads to complications such as non-union and shoulder stiffness. Surgical fixation with a dynamic compression plate (DCP) has been the gold standard treatment. Intramedullary nailing (IMN) has recently gained popularity due to its minimally invasive approach and reduced risk of radial nerve injury. This study aims to compare the outcomes of IMN and plate fixation for humeral shaft fractures. Methods: This retrospective study included patients with humeral shaft fractures treated with either IMN or DCP fixation at Hamad General Hospital between April 2015 and October 2018. Patient demographics, fracture characteristics, surgical outcomes, and complications were collected. Descriptive statistics were used to summarize patient information, and univariate analysis was conducted to compare both groups. A Cox proportional hazards model, adjusted for age, gender, and polytrauma status was applied to compare time to union between IMN and DCP groups. Results: Sixty five patients (25 IMN, 40 plate fixation) were included. Non-union rates were higher in the DCP group than in the IMN group (13% vs. 4%). Reoperation rates were also higher in the DCP group (20% vs. 4%). Postoperative neuropathy rates were 4% for IMN and 10% for DCP, with neuropathy resolution significantly higher in the IMN group (92% vs. 68%). Shoulder range of motion (ROM) and pain favored the DCP group, with 98% unaffected ROM in the plate group compared to 76% in the IMN group (p = 0.007), and a lower incidence of shoulder pain (28% vs. 98%, p < 0.001). Time to union was comparable between both groups, with an adjusted hazard ratio of 1.08 (95% CI 0.62–1.90; p = 0.776). Conclusion: IMN and plate fixation effectively achieved fracture union; however, plate fixation was associated with better shoulder function, reduced pain, and higher reoperation rates. IMN was linked to a lower risk of nerve injury but compromised shoulder ROM and resulted in more postoperative pain. [ABSTRACT FROM AUTHOR]

Background: Spasticity is a known complication to the hemiplegic shoulder following acquired brain injury. However, there is a current discrepancy between the diagnosis of arm spasticity and the subsequent assessment and treatment of spasticity in people with shoulder involvement. Objective: An expert panel aimed to establish a consensus and provide a simple structured approach to identifying and assessing people with spasticity of the hemiplegic shoulder. Methods: A consensus group of six spasticity experts were interviewed individually via 1-h video calls to ascertain how they assess people with arm spasticity for shoulder involvement. During an in-person meeting in March 2023, a consensus-building process was used to discuss four topics: a checklist/tool to identify shoulder involvement in upper limb spasticity, measurements/scales for assessing shoulder spasticity, 'red flags' for other conditions affecting the shoulder, and assessment limitations and practicalities. Results: Where there was full agreement on a topic, recommendations to overcome challenges for initial and ongoing assessment of shoulder spasticity and goal-setting were developed, and categorized as Posture, Purposeful activity and Pain ('the three Ps'). Posture should be observed when sitting and walking, as appropriate for the person, and compared to published shoulder spasticity patterns. Purposeful activity should be assessed using a systematic approach. The presence and nature of shoulder pain should be ascertained. Recommendations on impairment- and function-related measures are given. Conclusion: This consensus guidance provides practical recommendations on identifying shoulder spasticity to support clinicians in their management of people with neurological shoulder dysfunction. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to assess the efficacy of a pain neuroscience education program completed by patients with shoulder pain. Methods: A randomized, controlled trial was performed. Fifty-five patients satisfied the eligibility criteria, agreed to participate, and were randomized into an experimental group (n = 27) or control group (n = 28). A manual therapy and exercises program was administered for both groups. The experimental group also received a 4-week pain neuroscience education protocol (1 session/week, 75 min per session). The measurements taken included the active range of motion, pain, disability, catastrophizing, kinesiophobia, and therapeutic alliance. The outcomes were assessed at baseline and 5 weeks after completion of treatment. The primary outcome analyzed was the group × time interaction. Results: The 2 × 2 analysis of variance revealed a significant group × time interaction for the active range of motion (F = 15.27; p = 0.011), disability (F = 6.14; p = 0.01), catastrophizing (F = 8.79; p = 0.01), kinesiophobia (F = 7.62; p = 0.008), and therapeutic alliance (p = 0.03) in favor of the experimental group. Conclusions: This study showed that the patients with shoulder pain who completed the pain neuroscience program achieved significantly better results in terms of their active range of motion, disability, catastrophizing, kinesiophobia, and therapeutic alliance compared to those achieved by the control group. Therefore, pain neuroscience education may be beneficial in the treatment of patients with shoulder pain. [ABSTRACT FROM AUTHOR]

Background: Rotator cuff-related shoulder pain (RCRSP) is a prevalent musculoskeletal issue, encompassing various shoulder conditions. While exercise typically forms the foundation of conservative treatment, there exists ongoing discourse regarding the effectiveness and role of passive treatments. International guidelines recommend initial conservative management, with surgery considered only after failed conservative treatment. However, recent studies reveal discrepancies between recommended practices and actual clinical management. The aim of the study was to assess current practices in managing RCRSP among Greek physiotherapists, with a focus on understanding the alignment of these practices with international guidelines for conservative treatment. Methods: A cross-sectional survey was conducted among Greek physiotherapists to assess current practices in managing RCRSP. The survey, adapted from previous studies, collected demographic data and assessed clinical reasoning through a vignette-based approach. Responses were analyzed for alignment with guideline-recommended care. Results: Out of over 9000 contacted physiotherapists, 163 responded. A majority expressed a specific interest in shoulder pain (85%). Patient education (100%) and exercise (100%) were widely endorsed, with limited support for imaging (44%), injection (40%), and surgery (26%). Younger respondents were less inclined towards surgical referral (p = 0.001). Additionally, adjunctive interventions like mobilization (66%) and massage therapy (58%) were commonly employed alongside exercise and education. Treatment duration typically ranged from 6 to 8 weeks, with exercises reviewed weekly. Conclusions: The study highlights a consistent preference for conservative management among Greek physiotherapists, aligning with international guidelines. However, there are variations in practice, particularly regarding adjunctive interventions and exercise prescription parameters. Notably, there is a disparity between recommended and actual use of certain modalities. [ABSTRACT FROM AUTHOR]

Objective: Non-traumatic musculoskeletal shoulder disorders are common. Their treatment, surgical or non-surgical, is associated with a considerable financial burden to health systems. The aim of this study was therefore to investigate the cost-effectiveness of surgical or rehabilitative treatments in this population. Data sources: PubMed, Embase, NHS Economic Evaluation Database, Cost-Effectiveness Analysis registry, PEDro Database, Cochrane Library, and Google Scholar. Review methods: Trial-based economic evaluations assessing nonoperative and/or operative interventions for the management of non-traumatic shoulder disorders, published from January 2000 to October 2024, were searched. The selection process, data extraction and quality assessment (carried out with the Quality of Health Economic Studies instrument) were independently conducted by two reviewers. Results: Four studies (883 patients) were included in the review. Subacromial decompression for rotator cuff-related shoulder pain was found not to be cost-effective when compared with physiotherapy. Although it was not as cost-effective, Physiotherapy could be a socially beneficial alternative to mobilisation under anaesthesia in the early management of a frozen shoulder, due to lower costs and the delays in accessing surgical management in the pain-predominant phase. Productivity loss was the main driver of costs. It was not possible to determine the cost-effectiveness of other shoulder-related disorders due to sparsity of evidence. Conclusion: Priority should be given to interventions that reduce productivity loss and facilitate patients' return to work as soon as possible. There is a definite need for multiplication and standardization of high-quality economic studies (and the trials they are based on) regarding the management of non-traumatic musculoskeletal shoulder disorders. [ABSTRACT FROM AUTHOR]

Background: There is limited evidence about exercise performance during postoperative immobilization. This study aimed to quantify the muscle activity in the immobilized shoulder girdle in an abduction and neutral rotation position during a battery of contralateral activities and ipsilateral exercises of the upper limb in healthy volunteers and patients with unilateral shoulder pain (USP). Methods: Thirty participants were included and grouped as without (N = 17) or with USP (N = 13). Muscle activity (percentage of maximum voluntary isometric contraction (%MVIC)) of the serratus anterior (SA), upper trapezius (UT), lower trapezius (LT) and infraspinatus muscles was assessed during five contralateral activities (during comfortable speed, fast speed and comfortable speed with additional load) and seven ipsilateral exercises. Results: No differences in % MVIC were found between healthy volunteers and patients with USP on immobilized upper limb exercises and with the contralateral shoulder girdle. General muscle activity was low (<15% MVIC) to moderate (21–40% MVIC). This similarity was maintained at different speeds and with additional load. Adapted lawnmower exercise showed a favorable UT/LT activation ratio. Conclusion: The study results support the use of all evaluated shoulder exercises, as they have shown low muscle activity, which is important for early rehabilitation phases. [ABSTRACT FROM AUTHOR]

Long head of the biceps tendon pathology is a well-described proximal shoulder pain generator. While optimal treatment strategy remains controversial, popular operative management includes biceps tenodesis. However, appropriate restoration of the anatomic length–tension relationship of the biceps with tenodesis remains a challenge. We aim to describe a patient-specific technique utilizing a mini-open subpectoral approach to mark the long head of the biceps myotendinous junction location within the intertubercular groove prior to arthroscopic origin tenotomy. This technique offers the ability to restore anatomic tensioning of the long head of the biceps without relying on variable anatomic relationships, additional portals, tools, or technical challenges. [ABSTRACT FROM AUTHOR]

Background: Lacertus syndrome, a condition characterized by median nerve compression at the elbow due to anatomical variations, is often misdiagnosed. This case report describes a 53-year-old female patient who presented with severe lateral elbow and shoulder pain, previously diagnosed with cervicalgia and tennis elbow. Methods: Upon admission, she reported significant pain (NRS—Numerical Rating Scale 8/10) and occasional radiating paresthesia in the first three digits of her left hand. Clinical examination revealed weakness in the wrist and finger flexion, which was exacerbated by a positive Cutaneous Scratch Test (CST), while Magnetic Resonance Imaging (MRI) of the cervical spine showed no definitive abnormalities. Electroneurography (ENG) indicated reduced amplitude in the left anterior interosseous nerve. Ultrasound excluded carpal tunnel syndrome but identified nerve flattening beneath the pronator teres muscle. A surgical decompression of the median nerve was performed, resulting in immediate improvement in muscle strength and significant pain reduction (NRS 1/10) postoperatively. Follow-up evaluations confirmed substantial recovery in nerve function and morphology. Conclusions: This case illustrates the atypical presentation of Lacertus syndrome, emphasizing the need for comprehensive diagnostic approaches that include clinical, imaging, and neurophysiological assessments. Awareness of this syndrome is crucial for differential diagnosis in patients exhibiting uncharacteristic symptoms, such as shoulder or elbow pain, to ensure timely and effective treatment. [ABSTRACT FROM AUTHOR]

The article focuses on a case study of unilateral trapezius atrophy in a college baseball player, exploring its clinical implications. Topics include the potential causes of the condition, the diagnostic approach for identifying trapezius atrophy, and the treatment strategies for athletes experiencing muscle wasting.

Observational evaluation of arm elevation is a routine part of the examination of patients with shoulder pain and dysfunction. However, the interdependency of the glenohumeral and scapulothoracic joints during arm elevation presents a challenge for clinicians when attempting to characterize movement impairments and underlying causes. Given that identification of movement impairments related to the scapulothoracic joint (i.e. scapular winging or excessive scapular elevation) are more easily observed compared to movement faults at the glenohumeral joint (i.e. superior or anterior translation of the humeral head) an inherent bias may exist in which clinicians prioritize movement impairments and associated physical impairments at the scapulothoracic joint in developing a treatment plan. Interpreting the cause(s) of abnormal scapulothoracic motion without considering the potential influence of the glenohumeral joint (and vice-versa) may lead to faulty clinical reasoning when developing a plan of care. The purpose of this clinical commentary is to highlight the potential impact of faulty glenohumeral joint mechanics as being contributory to scapulothoracic joint kinematics. We first review the normal kinematics and muscular actions associated with typical arm elevation and then discuss how impairments at the glenohumeral joint may be contributory to faulty scapulothoracic motion. Specifically, we address movement faults characterized by excessive motion of the scapula. Level of Evidence: 5 [ABSTRACT FROM AUTHOR]

Objective. Polymyalgia rheumatica (PMR) is an inflammatory disorder of the elderly characterized by girdle pain and stiffness. Obesity has an influence on disease activity and outcome in rheumatic diseases like osteoarthritis and rheumatoid arthritis. We aimed to investigate the relationship between high BMI and the severity and outcome of PMR, which is incompletely understood. Methods. In a post hoc analysis, 83 patients with recent-onset PMR were studied over 6 months using clinical examination, laboratory evaluation, and girdle ultrasound (US). The modified Health Assessment Questionnaire (mHAQ), 36-item Short Form Health Survey (SF-36), and PMR visual analog scale (VAS) scores, as well as prednisone therapy data, were recorded. Patients were grouped according to their BMI. Results. At baseline, the 12 patients with obesity had significantly more shoulder pain (P = 0.03), global pain (P = 0.03), PMR VAS (P < 0.01), and fatigue (P = 0.03); higher mHAQ (P = 0.01); and lower SF-36 physical component summary (P = 0.048) and SF-36 pain index (P < 0.001). The mean initial prednisone dose was similar among groups, but patients with obesity received a lower dose/kg (1.9 [SD 0.7] mg vs 2.2 [SD 0.7] mg; P < 0.01). At 6 months, patients with obesity were being treated with higher mean daily prednisone doses (8.5 [SD 3.2] mg/d vs 6.2 [SD 5.2] mg/d; P = 0.02), and 40% of them were receiving higher daily prednisone doses than the standard protocol compared with 14% patients without obesity (P = 0.048). Clinical features, laboratory results, and US results were similar between patients with and without obesity. Conclusion. Obesity affects both symptom severity and prednisone utilization in patients with PMR. The reason for this may relate to different subjective pain perception rather than increased inflammation in patients with obesity. BMI should be considered when interpreting symptoms in patients with PMR and deciding their prednisone doses. [ABSTRACT FROM AUTHOR]

Objective: To investigate differences in the microstructure of the spinothalamic tract (STT) white matter in people with chronic neck and shoulder pain (CNSP) using diffusion tensor imaging, and to assess its correlation with pain intensity and duration of the pain. Materials and methods: A 3.0T MRI scanner was used to perform diffusion tensor imaging scans on 31 people with CNSP and 24 healthy controls (HCs), employing the Automatic Fiber Segmentation and Quantification (AFQ) method to extract the STT and quantitatively analyze the fractional anisotropy (FA) and mean diffusivity (MD), reflecting the microstructural integrity of nerve fibers. Correlations of these differences with duration of pain and visual analog scale (VAS) scores were analyzed. Results: No significant differences in the mean FA or MD values of the bilateral STT were observed between people with CNSP and HCs (p > 0.05), as indicated by the two-sample t test. Further point-by-point comparison along 100 equidistant nodes within the STT pathway revealed significant reductions in FA values in the left (segments 12–18, 81–89) and right (segments 9–19, 76–80) STT in the CNSP group compared to HCs; significant increases in MD values were observed in the left (segments 1–13, 26–30, 71–91) and right (segments 8–17, 76–91) STT (p < 0.05, FWE corrected). Partial correlation analysis indicates that in people with CNSP, the FA values of the STT in regions with damaged white matter structure show a negative correlation with VAS scores and duration of pain, whereas MD values show a positive correlation with VAS scores and duration of pain. Conclusion: This study found that people with CNSP exhibit white matter microstructural abnormalities in the specific segments of STT. These abnormalities are associated with the patient's pain intensity and disease duration. The findings offer a new neuroimaging perspective on the pathophysiological basis of chronic pain in the ascending conduction process and its potential role in developing targeted intervention strategies. However, due to the limited sample size and the lack of statistical significance when analyzing the entire spinothalamic tract, these conclusions should be interpreted with caution. Further research with larger cohorts is necessary to validate these results. [ABSTRACT FROM AUTHOR]

Background: Clavicle fractures associated with ipsilateral coracoid process fractures are very rare, with limited literature reporting only a few cases. This study reports on 27 patients with ipsilateral concomitant fractures of the clavicle and coracoid process who were followed for more than 12 months. Material and methods: This retrospective study reviewed the charts of skeletally mature patients with traumatic ipsilateral clavicle and coracoid process fractures treated at the authors' institution. Each patient was regularly followed post-treatment. Radiographs assessed bone union and implant integrity, while clinical evaluations included the Constant–Murley score for shoulder function; disability of the arm, shoulder, and hand (DASH) questionnaire for upper limb function; and visual analog scale score for pain. Complications were also recorded. Results: From October 2012 to February 2023, 40 patients were diagnosed with ipsilateral fractures of the clavicle and coracoid process of the scapula, accounting for 1.4% (40/2877) of all clavicle fractures and 5.2% (40/786) of all scapular fractures. This study included 27 patients with follow-up exceeding 12 months: 6 had medial-third clavicle fractures, 12 had middle-third fractures, and 9 had distal-third fractures. According to Eyres' classification, the coracoid fractures included two type I, five type II, eight type III, seven type IV, and five type V fractures. Twenty-two patients received operative treatment, with clavicle fractures fixed with internal plating and 11 coracoid fractures with internal fixation. Bone union was achieved in all patients. The mean Constant–Murley score was 91.2 ± 9.4 and the mean DASH score was 6.4 ± 7.6. Five patients reported mild shoulder pain and five patients developed complications. Conclusions: Ipsilateral concomitant fractures of the clavicle and coracoid process can occur at various clavicle locations, with shaft and medial fractures more common than previously thought. Displaced fractures can be effectively managed with operative treatment, and coracoid process fixation may not be necessary if satisfactory indirect reduction is achieved after clavicle fixation. Level of evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Neck and shoulder pain (NSP) is a common issue among college students, yet no studies have linked digital device usage to NSP prevalence in China. This cross-sectional survey aimed to explore this relationship among students in Shanghai. A total of 6,000 students were randomly selected, with 4,848 (80.8%) completing a self-reported questionnaire on NSP prevalence and severity. The results showed a 39.1% NSP prevalence, higher in females (45.0%) than males (32.4%). Logistic regression revealed significant correlations between NSP and factors such as gender, poor posture, and prolonged digital device use. Additionally, neck muscle activity increased with spinal inclination, as assessed by the AnyBody platform. The findings suggest promoting a healthy spinal curvature lifestyle to reduce NSP among college students.. [ABSTRACT FROM AUTHOR]

Objective: To investigate the prevalence of neck and LBP and epidemiological characteristics in army of plateau with an analysis and evaluation of risk factors, and provide theoretical basis for specific diagnosis and treatment, as well as guidance of taking protective measures effectively.Methods: The symptom was investigated epidemiologically by questionnaires, physical examinations and field visits in 586 in 5 regions. The data of prevalence of chronic pain, the epidemiological characteristics in distribution, the etiology and relevant risk factors analyzed by statistical method. Results: The total prevalence of neck and LBP was 57. 34 %, 36. 27 % for neck pain, and 51. 12 % for LBP. Time of car,working bow hours and muscle exercise were identified as high risk factors for neck and LBP. The total prevalence of injuries of shoulder and knee was 31. 43 %, 15. 37 % for shoulder, and 24. 87 % for knee.Age, injury Working hours and muscle exercise were identified as high risk factors for discomfort of shoulder and knee. Conclusions: The prevalence of neck pain and LBP and the injury of shoulder and knee of army in plateau was high. The cause of pain is rather complicated, which is due to many factors. Training of cervical muscles and psoas, popularization of science and the scientific organization,relevant devices and protective measures are all important ways to prevent neck and low back pain and injuries of shoulder and knee. [ABSTRACT FROM AUTHOR]

Purpose: To cross-culturally adapt the Patient-Specific Functional Scale (PSFS) into Italian and study its classic psychometric properties in subjects with shoulder pain (SP). Materials and Methods: The PSFS was translated into Italian and administered to 109 SP subjects. Acceptability (time to administer, floor and ceiling effects), reliability (internal consistency [Cronbach's alpha], test-retest reliability [Intraclass Correlation Coefficient (ICC)], and measurement error [Standard Error of Measurement (SEM), Minimal Detectable Change, (MDC)]), were assessed. Moreover, construct validity was investigated through a-priori hypothesis testing, comparing the PSFS with the Disability of the Shoulder, Arm and Hand (DASH) scale, 36-item Short Form Health Survey (SF-36) and Numeric Pain Rating scale (NPRS). Results: The PSFS was successfully adapted into Italian, and its acceptability was satisfied. Internal consistency was high (Cronbach's alpha = 0.925), and test-retest reliability was good (ICC = 0.866, 95% CI = 0.749–0.931). A SEM of 0.7 points and an MDC of 1.9 points were obtained. We observed moderate evidence for construct validity, with 4/6 correlations between other measures being respected. Conclusion: This study provided reliability and validity of the PSFS in a sample of Italian SP subjects. Future studies should assess the responsiveness of using the PSFS as an outcome measure to capture clinical changes after treatment. IMPLICATION FOR REHABILITATION: The Patient-Specific Functional Scale is a reliable, and easy-to-use patient-reported outcome measure. The Patient-Specific Functional Scale was cross-cultural validated in the Italian language. The Patient-Specific Functional Scale has excellent internal consistency, high reliability, low measurement error, and moderate construct validity in subjects with shoulder pain. The Patient-Specific Functional Scale can be used in clinical practice by Italian physiotherapists to assess subjects with shoulder pain. [ABSTRACT FROM AUTHOR]

Acromioclavicular joint osteoarthritis is prevalent in middle-aged and older people, causing shoulder pain and functional limitations. Despite its prevalence, there are inconsistencies in the physical diagnosis procedures practiced in clinical tests. A recent study introduced a novel hand-behind-the-back (HBB) test, a promising alternative to the traditional cross-body adduction (CBA) test. However, further study was suggested to validate the results obtained. So, this study predicted muscle forces for the cross-body adduction and hand-behind-the-back tests using OpenSim and the AnyBody Modeling System™. This work redefined the joint kinematics for the tests and performed an inverse dynamics analysis to solve the muscle redundancy problem using the generic upper extremity dynamic models available in OpenSim and AnyBody Modeling System™. The results revealed some agreements and significant discrepancies in most muscle force predictions between the OpenSim and AnyBody Modeling SystemTM. Thus, this study underscores the necessity of integrating multiple modeling approaches and comprehensive validation, including experimental data, to enhance the accuracy and reliability of muscle force predictions in shoulder biomechanics during CBA and HBB tests. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to examine the differences in shoulder ultrasonographic parameters between overhead aquatic athletes and their relationship with shoulder pain. Methods: Sixty-four healthy junior subjects (n = 128 shoulders) participated in the study, including 17 healthy controls, 25 elite junior swimmers, and 22 elite junior water polo players. An ultrasonographic study of the shoulder was carried out to measure the thickness of the rotator cuff structures in sex- and age-paired groups. Results: Compared to controls, female and male swimmers and water polo players had thicker values in the rotator cuff tendons, including the subscapularis (SSB) (p < 0.001), supraspinatus (p < 0.001), infraspinatus (p < 0.001) and teres minor (Tm) (p < 0.025). The female swimmers had thicker values than the water polo players in the SSB (p < 0.001) and Tm (p < 0.011). In the comparison by sexes, the female controls had a thinner LHBB, SSB and Tm (p < 0.019), the female swimmers had a thinner ISP (p = 0.001), and the female water polo players had a thinner LHBB, SSB, ISP and acromiohumeral distance than their group-paired counterparts (p < 0.018). Finally, the females had a lower incidence of positive Jobe test results compared to the males (p = 0.018), which was associated with lower pain scores at rest (p < 0.034) and during training (p < 0.036). Conclusions: The rotator cuff tendon structures were larger in the healthy overhead aquatic athletes compared to the age- and sex-paired controls. The females had smaller values in the shoulder ultrasonographic tendon parameters compared to the age- and sport-paired males, except for the supraspinatus tendon. [ABSTRACT FROM AUTHOR]

Background: Workers in home care have high sick leave rates, predominantly because of musculoskeletal pain. The Goldilocks Work Principle proposes that health should be promoted by a "just right" composition of work tasks. Weekly workloads differ substantially between home care workers, suggesting that certain workers may have workloads that are too high, impacting their musculoskeletal health. The aim of this study was to evaluate the effectiveness of a "GoldiCare" intervention redistributing weekly workloads to become more equal among the homecare workers. Outcomes were pain in the neck/shoulder and lower back, and the implementation of the intervention was also evaluated. Methods: A 16-week cluster randomized controlled trial was conducted with 125 workers from 11 home care units, divided into six intervention units and five control units. The operation coordinators of each intervention unit were educated in the Goldilocks Work Principle and provided with a planning tool to facilitate an even distribution of high care need clients. The control group continued their usual work. Primary outcomes were pain intensity in the neck/shoulder and lower back (0 to 10). Secondary outcomes included fatigue (0 to 10), composition of physical behaviors and postures (accelerometers), adherence to the intervention (weekly usage rates of the planning tool), and performance of the intervention (percentage of workers with an even distribution of workload). Results: The analysis showed no difference between the intervention and control groups in change in lower back pain (0.07, 95%CI[-0.29;0.43]), neck/shoulder pain (-0.06, 95%CI[-0.49;0.36]) or fatigue (0.04, 95%CI[-0.52;0.61]. No significant changes were observed in the composition of physical behaviors (p = 0.067) or postures (p = 0.080–0.131) between the two groups. The intervention was succesfully implemented in three units of the six, with adherence ranging from 82–100% across the intervention period. The remaining three units had an adherence of 0–47%. No improvement in performance was observed. Conclusion: No significant intervention effects were observed on musculoskeletal pain, fatigue, or the composition of physical behaviors and postures. The findings suggest that the intervention was not adequately implemented within the organization. Consequently, we cannot discern whether the lack of positive results were due to poor implementation or an ineffective intervention. Results thus highlight the need for a more comprehensive understanding of organizational structures within home care to facilitate more effective implementations. The hypothetical effectiveness of a fully implemented intervention remains unknown. Trial registration: Clinicaltrials.gov ID: NCT05487027, submitted: 03/08/2022. [ABSTRACT FROM AUTHOR]

To compare the effects of High-Intensity Laser Therapy (HILT) versus Low-Level Laser Therapy (LLLT) on shoulder pain and disability, shoulder Range of Motion (ROM), Pain Pressure Threshold (PPT), and sleep quality of patients having Subacromial Impingement Syndrome (SAIS). Forty-two patients with SAIS were randomly assigned into three groups, the HILT group (n = 14), the LLLT group (n = 14), and control group (n = 14). All groups received an exercise program consisted of shoulder muscles stretching and strengthening exercises. Along with the exercise program, the HILT group received HILT at 810 nm /980 nm, and LLLT group received LLLT at 904 nm, three times weekly for three weeks. The primary outcome was the change in shoulder pain and disability measured by Shoulder Pain and Disability Index (SPADI). Secondary outcomes included shoulder ROM using a standard goniometer, PPT measured by pressure algometer, and sleep quality by Pittsburgh Sleep Quality Index (PSQI). Measurements were taken both before and after a 3-week intervention to assess the outcomes. After 3-wk intervention, both the HILT and LLLT groups exhibited significant improvements in all parameters when compared to the control group (p < 0.05). Additionally, there were clinically significant differences between groups supported by a large ES favoring the HILT group for SPADI pain (ηp2 = 0.71), SPADI disability (ηp2 = 0.54), SPADI total (ηp2 = 0.82), PPT (ηp2 = 0.63), and PSQI (ηp2 = 0.42). The combination of HILT with exercises proved to be more beneficial in enhancing pain and function, PPT, and sleep quality compared to LLLT combined with exercises in treating patients with SAIS. [ABSTRACT FROM AUTHOR]

Background: Evidence indicates that central sensitization (CS) plays a role in subacromial impingement syndrome (SIS). Reduced treatment response has been associated with pretreatment pain sensitization features, such as CSrelated symptoms. Methods: Patients who received subacromial steroid injection were evaluated before the injection, at the first and third months. CS-related symptoms were investigated through the central sensitization inventory (CSI), and pain hypersensitivity was investigated by pressure pain threshold (PPT). Patients were evaluated using the visual analog scale (VAS), Quick Disabilities of the Arm, Shoulder, and Hand, Hospital Anxiety and Depression Scale, and Short Form-36. Results: With the injection, all participants had a significant reduction in shoulder pain (P < 0.05). In all follow-ups, VAS values did not differ significantly between the groups, and patients with CSI = 40 had higher levels of disability, anxiety, depression, and worse quality of life before treatment (P < 0.05). Post-injection disability decreased significantly in the CS group and reached similar levels in both groups at the third month (P > 0.05). Although both groups' PPT values were comparable pre-treatment and at the third month, the CS group's affected shoulder showed a notable PPT decline at the first month (P < 0.05). Conclusions: Pre-treatment CS-related symptoms had no effect on SIS patients' responsiveness to steroid injections. [ABSTRACT FROM AUTHOR]

Objective • This study aims to evaluate the clinical efficacy and safety of combining adhesion release under brachial plexus block with silver needle warm acupuncture for the treatment of frozen shoulder, compared to adhesion release under brachial plexus block alone. Methods • A total of 72 patients with frozen shoulder were randomly assigned to receive either adhesion release under brachial plexus block (control group) or adhesion release under brachial plexus block plus silver needle warm acupuncture (treatment group). Outcome measures included changes in shoulder pain scores assessed using the Visual Analog Scale (VAS), shoulder mobility scores evaluated using the Constant-Murley Score, shoulder function scores measured using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and overall clinical outcomes based on a comprehensive evaluation. Both groups received functional exercise 2 days after the operation, and the treatment duration was 3 weeks. Results • The treatment group exhibited a mean reduction in shoulder pain scores of 3.2 points on the Short-form McGill pain scores, while the control group showed a reduction of 1.5 points. Shoulder mobility scores, assessed by the Constant-Murley Score, increased by an average of 18.6 points in the treatment group, compared to 9.2 points in the control group. Moreover, the treatment group achieved better shoulder function scores on the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, with an average improvement of 25.4 points, compared to 13.8 points in the control group. Conclusion • This study provides valuable insights into the clinical efficacy of adhesion release under brachial plexus block plus silver needle warm acupuncture for frozen shoulder, there are still areas that warrant further investigation. Future research could focus on the longterm effects of the treatment, optimal treatment duration and frequency, comparison with other treatment modalities, and the inclusion of larger sample sizes to enhance the robustness of the findings. [ABSTRACT FROM AUTHOR]

The study aimed to identify expert opinions and obtain recommendations on the management of post-stroke hemiplegic shoulder pain (HSP) and treatment with botulinum toxin A (BoNT-A). A multicenter Delphi study was conducted using an online survey designed by a committee of experts with at least 10 years of experience in post-stroke HSP management with BoNT-A in Spain. Forty-seven panelists (specialists with at least 5 years of experience in post-stroke HSP management with BoNT-A) rated their level of agreement in two rounds based on acceptance by ≥66.7% of them. In round 1, 245 statements on three dimensions were evaluated (diagnosis, treatment, and follow-up of the HSP patients treated with BoNT-A). A total of 159 statements (70.9%) were finally accepted after round 2. Experts recommended BoNT-A as soon as spasticity affects daily activities. They considered ultrasound as the preferred guided technique. Experts recommended regular assessments using validated scales and patient-reported outcomes to evaluate treatment goals and safety. In case of lack of response, experts suggested increasing the dose or number of treated muscles or considering alternative treatments. These consensus-based recommendations offer clinicians an approach to the management of post-stroke HSP with BoNT-A, supporting informed decision making. [ABSTRACT FROM AUTHOR]

Background: Human placental hydrolysate (hPH) contains anti-inflammatory substances. This study aimed to analyze whether injecting hPH into the subacromial space could reduce pain in patients with shoulder impingement syndrome. Methods: This single-blind, randomized controlled study enrolled 50 patients with shoulder impingement syndrome who were randomly assigned to either the hPH or placebo groups. All patients received three ultrasound-guided subacromial space injections of 4 mL hPH or normal saline every week. Outcome measurements included the Visual Analog Scale (VAS) score during daily activity, Shoulder Pain and Disability Index (SPADI), and EuroQoL 5-Dimension 5-Level (EQ-5D-5L) utility index. Patients were followed up for nine weeks after the last injection. Results: Significant differences were noted in the VAS (p < 0.001) during daily activity, SPADI total score (p < 0.001), and EQ-5D-5L utility index (p < 0.001) nine weeks after the last injection between the hPH group and placebo group. Significant time effects were observed for all outcome measurements (all p < 0.001) in the hPH group but not in the placebo group. No severe complications, such as local infections or laboratory abnormalities, were reported during this study. Conclusions: Subacromial injections showed significant improvement in pain, functional level, and quality of life in patients with shoulder impingement syndrome. Therefore, hPH can be used as an alternative treatment for shoulder impingement syndrome. Trial registration: The trial was registered on www.Clinicaltrials.gov (NCT05528705, Registration Date: 06/09/2022). [ABSTRACT FROM AUTHOR]

This systematic review and meta-analysis aims to assess the effects of movement representation techniques (MRT) on pain, range of motion, functional outcomes, and pain-related fear in patients with non-specific shoulder pain (NSSP). A literature search conducted in PubMed, PEDro, EBSCO, Scopus, Cochrane Library, ScienceDirect, and gray literature on April 31, 2023. We selected seven randomized controlled trials based on the PICOS framework. Incomplete data or non-NSSP excluded. Study quality was assessed using the PEDro scale (mean score = 6.43), and certainty of evidence was evaluated with the GRADE approach. MRT demonstrated a large effect size for pain reduction (high heterogeneity, I2 = 85.2%, Hedges'g = 1.324, 95% CI = 0.388–2.260, P = 0.006), functional improvement (moderate heterogeneity, I2 = 70.82%, Hedges'g = 1.263, 95% CI = 0.622–1.904, P < 0.001), and reduction of pain-related fear (moderate heterogeneity, I2 = 70.86%, Hedges'g = 0.968, 95% CI = 0.221–1.716, P < 0.001). MRT also showed significant benefits for range of motion, particularly in flexion (low heterogeneity, I2 = 26.38%, Hedges'g = 0.683), abduction (low heterogeneity, I2 = 33.27%, Hedges'g = 0.756), and external rotation (low heterogeneity, I2 = 48.33%, Hedges'g = 0.542) (P < 0.001 for all), while no significant effect was found for internal rotation (P > 0.05). No publication bias was detected. While limited evidence and methodological concerns necessitate further research, MRT appears to positively impact pain, range of motion, functional outcomes, and pain-related fear in NSSP patients. [ABSTRACT FROM AUTHOR]

Background: Alleviating inflammation should be considered as one of the first steps of the treatment plan in patients with acute rotator cuff related shoulder pain (RCRSP). Objective: To compare the effects of triamcinolone/lidocaine ultrasonophoresis, injection on pain, disability, and quality of life in patients with acute RCRSP. Methods: A total of 28 acute RCRSP patients were randomly allocated into two groups of ultrasonophoresis and injection. Both groups received vitamin C and shoulder care education for 10 days and then were subjected to therapeutic interventions. Ultrasonophoresis group received triamcinolone (16 mg) and lidocaine (2mg) using ultrasonophoresis (frequency: 3 MHz, intensity: 1.50 W/Cm2), while the injection group received a single subacromial injection of triamcinolone (80 mg) and lidocaine (10 mg). The main outcomes measures were pain assessed by two scales (visual analog scale), and shoulder pain and disability index (SPADI), disability (SPADI), and quality of life (Western Ontario rotator cuff questionnaire). Results: Although the main effect of time was statistically significant for all dependent variables (P< 0.01), no significant interaction was found between group and time (P-value (0.12-0.55)). The ultrasonophoresis effect, size for pain, disability, and quality of life were 2.58, 1.43, 1.78, and 1.35, respectively. The injection effect, size for pain, disability, and quality of life were 1.98, 2.02, 1.40, and 1.60, respectively. Conclusions: Triamcinolone/lidocaine ultrasonophoresis demonstrated similar outcomes to injection in reducing pain, improving disability, and enhancing quality of life in patients with acute RCRSP in short time. According to our findings, ultrasonophoresis with triamcinolone/lidocaine cream is as effective as triamcinolone/lidocaine injection and can be proposed as a potential adjunctive treatment for patients with acute RCRSP. [ABSTRACT FROM AUTHOR]

Background: Research is supporting thoracic spine manipulation (TSM) as an intervention in treating adhesive capsulitis (AC) when coupled with physical therapy interventions. Purpose: To investigate whether TSM improves AC outcomes when combined with physical therapy interventions. Method: A double-blinded, randomized, controlled trial with 40 patients assigned into two groups. The experimental group (EG) received physical therapy intervention and TSM; the control group (CG) had physical therapy with sham manipulation. Both groups received interventions biweekly for 12 weeks. Outcomes included Visual Analogue Scale (VAS), Shoulder Pain and Disability Index (SPADI), scapular upward rotation, and shoulder passive range of motion conducted at baseline, after 1 session, 6 and 12 weeks. Results: Both groups improved significantly after 6 and 12 weeks in pain, disability (p = 0.01 for both; d = 1.53 and 1.46, respectively), scapular upward rotation, shoulder flexion (p = 0.02 for both; d = 2.2 and 0.92, respectively), abduction (p = 0.04; d = 0.07), and external rotation (p = 0.03; d = 0.7). However, CG showed no significant improvement in pain or disability after one session (p = 0.14 and p = 0.16, respectively; d = 0.46 for both). Between groups, results favored EG significantly in pain, disability, scapular upward rotation, shoulder flexion, and abduction (p = 0.02, p = 0.01, p = 0.02, p = 0.05, and p = 0.04, respectively) at 6 weeks (d = 0.81, d = 0.87, d = 0.67, d = 0.64, and d = 0.69, respectively). Conclusion: The results suggest that adding TSM yielded superior clinical benefits when compared to physical therapy interventions in AC patients. Nevertheless, it is imperative to acknowledge a specific limitation in our study is the omission of passive internal rotation assessment. This aspect represents a notable constraint in our research. Clinical trial registry number: Pan African clinical trial registry "PACTR202303495421928" [ABSTRACT FROM AUTHOR]

Background: Quadrilateral space syndrome is a painful disorder of the shoulder caused by static or dynamic entrapment of the axillary nerve and the posterior humeral circumflex artery. It was first described in 1983; however, it is an uncommon syndrome that initially presents with nonspecific shoulder pain or selective deltoid atrophy, and diagnosis is often delayed owing to its rarity. Young athletes of overhead sports are more commonly affected by this syndrome. Symptoms of quadrilateral space syndrome include silent deltoid atrophy, persistent posterior shoulder pain, paresthesias, and tenderness over the quadrilateral space. Vascular symptoms may involve thrombosis and embolisms of the upper limb. Instrumental tests and imaging are not always conclusive, leading to frequent misdiagnosis of the syndrome. Patients and methods: The aim of this study is to present a case series of four patients diagnosed with neurogenic quadrilateral space syndrome, describe different clinical presentations, and suggest tips for diagnosing this syndrome. All patients underwent a detailed medical history collection, were interviewed about the sports and hobbies they engaged in, and received a comprehensive clinical examination of the neck and shoulder. Patients also underwent diagnostic exams such as magnetic resonance imaging (MRI) and electromyography. An ultrasound-guided injection of local anesthetic was performed into the quadrilateral space. Results: All patients affected by neurogenic quadrilateral space syndrome underwent conservative treatment, which included a rehabilitation program. Only one out of four patients experienced complete resolution of symptoms and did not require surgical decompression. Conclusions: To properly treat this rare syndrome, we propose classifying it as either "dynamic" or "static," on the basis of the clinical history, MRI findings, and physical examination. The study includes a rehabilitation program that was effective for one patient, demonstrating that surgical decompression may be avoidable if the cases are promptly diagnosed and classified. Level of evidence IV according to "The Oxford 2011 Levels of Evidence" [ABSTRACT FROM AUTHOR]

Background: Arthroscopic rotator cuff repair (RCR) is a common procedure, yet long-term patient-centered outcome studies remain limited. This study aims to evaluate the outcomes of arthroscopic RCR using a single-row metallic anchor technique over a 12-year follow-up, focusing on patient-reported outcomes and potential risk factors. Methods: A monocentric cohort study was conducted on patients who underwent complete arthroscopic RCR with a single-row metallic anchor technique from January 2007 to July 2011. A total of 628 patients completed three standardized questionnaires: Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and the Simple Shoulder Test (SST). They were also asked for their overall satisfaction on the procedure with a single direct question. Outcomes were analyzed by gender, age at surgery, lesion pattern, and follow-up duration. Results: The mean follow-up period was 12.9 ± 1.3 years. Overall satisfaction was 96.5%. The mean scores for QuickDASH, ASES, and SST were 7.2 ± 15.7, 83.8 ± 23.9, and 89.9 ± 22.3, respectively. Female patients reported significantly lower QuickDASH (p < 0.001), ASES (p < 0.001), and SST (p = 0.004) than male patients, but overall satisfaction did not differ by gender. Age, number of tendons repaired, anterior tear, and follow-up length were not significantly associated with differences in outcome measures. Conclusions: Single-row arthroscopic RCR provides excellent long-term patient-reported outcomes and high patient satisfaction. Female gender may be associated with slightly lower functional scores, yet satisfaction remains unaffected. This study supports the single-row technique as a reliable, efficient, and cost-effective option for long-term success in RCR, challenging the need for more complex multi-anchor approaches. [ABSTRACT FROM AUTHOR]

This systematic review aimed to 1) verify bilateral symmetry assumption in manual wheelchair propulsion in daily life and sports, and its relationship with injury risk and sports performance, and 2) evaluate methods for assessing bilateral symmetry. Scopus, Web of Science, PubMed, and EBSCO databases were searched for articles published before January 2024 investigating bilateral symmetry in manual wheelchair users and/or healthy participants during manual wheelchair propulsion. Two independent reviewers screened, extracted data, and assessed methodological quality of retrieved papers. Twenty-five studies were included. In daily ground-level propulsion, minimal asymmetries were observed in kinematic, kinetic, and temporal parameters when averaging three or more push cycles. In the sports context, diverse findings emerged, ranging from up to 27% side-to-side differences in propulsion kinetics and kinematics during sprinting, to descriptions of both symmetrical and asymmetrical upper limb motions. Limited evidence exists regarding the role of asymmetry in manual wheelchair propulsion as a risk factor for injury and pain, as well as the association between sprinting performance and symmetry. In conclusion, bilateral symmetry assumption in manual wheelchair propulsion is valid only under specific conditions (i.e., slow/moderate speed, averaging ≥3 push cycles, smooth level ground). The wheeling environment and interindividual variability impact symmetry research outcome and require consideration in future studies. [ABSTRACT FROM AUTHOR]

Background: Shoulder pain can be caused by structures within the shoulder joint or external structure to shoulder and the prevalence of shoulder pain is high. Objective: The purpose was to investigate the ultrasonographic characteristics of patients with shoulder pain and to study the association between age groups (less than 60 years vs. 60 years and above) and commonly found abnormal ultrasonographic findings. Methods: A retrospective study was conducted on 253 patients experiencing shoulder pain over a month. Data included gender, age, side of pain, pain duration, painful area, previous treatments, clinical assessment of shoulder pain. The abnormal findings in shoulder ultrasound images were reported, and the association between age group with common ultrasound abnormalities were analyzed using the chi-square test. Results: Common abnormal ultrasound findings included subdeltoid bursitis (82.7%), biceps tendon effusion (48.7%), and supraspinatus tendinosis (44.2%). Moreover, patients aged 60 years and above had a significantly higher prevalence of biceps tendon effusion (53.6% vs 36.0%), supraspinatus tendon tear (19.3% vs 8.6%) and subscapularis tendon tear (6.1% vs 1.4%) compared to those aged less than 60 years. Conclusion: The common abnormal ultrasound findings in patients with shoulder pain were subdeltoid bursitis, biceps tendon effusion and supraspinatus tendinosis. Patients aged 60 years and above had a significantly higher prevalence of biceps tendon effusion and tears in the supraspinatus and subscapularis tendons. [ABSTRACT FROM AUTHOR]

Background/Objectives: Shoulder pain is a common treatment outcome in breast cancer survivors. While various risk factors and mechanisms for shoulder pain have been proposed, evidence is inconsistent. Increased risk of subacromial pain syndrome exists, which can lead to disability and reduced quality of life if untreated. Ultrasound is a valuable tool for detecting rotator cuff changes aiding in timely diagnosis of subacromial pain syndrome. This study aimed to assess the prevalence of rotator cuff changes to better understand chronic shoulder pain in breast cancer survivors. Methods: This cross-sectional study included 74 breast cancer survivors from the University Hospital Split. Data were collected via questionnaires and clinical interviews. Bilateral shoulder ultrasounds were performed by two blinded investigators. Categorical variables were analyzed using Chi-squared tests, and continuous variables were analyzed with T-tests or Mann–Whitney tests. Results: Pathological findings were similarly prevalent on the operated and non-operated sides (p = 0.3 and p = 0.6). Among participants with shoulder pain, ultrasound-detected pathology was present in 91% of right shoulders and 96% of left shoulders (p < 0.005). Non-painful shoulders exhibited pathology in 59% of right and 57% of left shoulders. Ipsilateral pain to the site of breast surgery was reported by 57.7% of participants, with supraspinatus pathology in 56%, acromioclavicular joint pathology in 39%, and subacromial–subdeltoid bursitis in 41%. Conclusions: Similar pathology distribution on operated and non-operated sides and frequent asymptomatic findings highlight unresolved causes of shoulder pain in breast cancer survivors. Ultrasound is valuable but requires integration with clinics for accurate diagnosis of the underlying causes of shoulder pain. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. The relationship between perception of harm, emotional valence in movement images, and their impact on disability in shoulder pain. Perception of harm correlates with disability. Recent studies highlight an interplay between pain perception and emotional responses. This necessitates a thorough investigation into how beliefs and motivational influences respond to visual stimuli of movements. Such an analysis is crucial for understanding the extent to which these factors contribute to disability levels associated with shoulder pain. We aimed to investigate the relationship between the perception of harm and the valence in images depicting shoulder movements and determine how these perceptions are linked to disability levels associated with shoulder pain. This cross-sectional study recruited 42 individuals with chronic shoulder pain. Participants were presented with 58 shoulder movements images. Each participant evaluated these images for emotional valence and arousal using the self-assessment manikin. For every image, they provided their level of avoidance, fear, and perception of harm in a numerical scale. We measured disability levels and pain catastrophizing using the Shoulder Pain and Disability Index and the Pain Catastrophizing Scale. A direct acyclic graph was used. Multiple linear regression analysis was conducted with shoulder disability as the dependent variable and perception of harm and valence as independent variables, adjusted for the confounders catastrophizing and arousal. This analysis resulted in a significant model (F 4,37 = 11.44; adjusted R 2 = 0.547; P < 0.01). The perception of harm to shoulder movement (β = 0.11; P < 0.001; 95% confidence interval = 5.6-11.8) was significantly associated with the level of shoulder disability, whereas valence did not show a significant association (β = 0.26; P = 0.15; 95% confidence interval = 1.7-10.8). The perception of harm associated with shoulder movements images during daily activities was associated with disability. Individuals who believe that shoulder movements are harmful have greater disability. [ABSTRACT FROM AUTHOR]

Background: Sternoclavicular joint (SCJ) instability can lead to pain, reduced function, and an inability to perform sports and activities of daily living. Reconstruction of the SCJ using hamstring autograft in a figure-of-8 configuration has demonstrated good outcomes at short- and midterm follow-ups, but there is a paucity of literature on long-term outcomes. Purpose: To evaluate the long-term clinical and functional outcomes after SCJ reconstruction, with a focus on return to sport, instability recurrence, and revision surgery. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent SCJ reconstruction with a hamstring autograft for the treatment of SCJ instability between December 2010 and June 2013 by a single surgeon with a minimum 10-year follow-up were eligible for inclusion. Patient-reported outcome measures, including the American Shoulder and Elbow Surgeons (ASES) Score, short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, and patient satisfaction (1-10 scale, with 10 indicating maximum satisfaction), rates of return to sport, instability recurrence, and revision surgery, were evaluated at short- (2-3 years), mid- (5-8 years), and long-term (minimum 10 years) follow-ups. Results: Eleven patients (13 shoulders) were evaluated at a median of 10.0 years (IQR, 10.0-11.0 years) postoperatively. SCJ instability was chronic in 12 shoulders (92.3%) and acute in 1 shoulder (7.7%). One shoulder underwent revision SCJ reconstruction and was excluded from further analysis (survivorship: 92.3%). Significant pre- to postoperative improvements in shoulder function and pain were observed at short-term follow-up and were either maintained or further improved at mid- and long-term follow-ups. At a minimum of 10 years postoperatively, shoulder function (median ASES score: 95.0 [IQR, 86.2-97.5]; median QuickDASH: 12.5 [IQR, 6.8-15.9]; median SANE: 89.0 [IQR, 81.5-96.3]) was excellent, pain levels were low (median VAS for pain: 0.5 [IQR, 0-1.8]), and patient satisfaction was high (median, 9.0 [IQR, 8.0-10]). All patients returned to sport (n = 10; 100%) at levels equal to or above (n = 3; 30.0%) or slightly below (n = 7; 70.0%) their preinjury level. Two of these patients (20.0%) reported instability-related modifications in activity. One patient had recurrent instability 2.5 years postoperatively but had excellent shoulder function at the final follow-up. The overall rate of instability recurrence was 36.4% (4/11 patients). Conclusion: SCJ reconstruction using a hamstring autograft for the treatment of SCJ instability resulted in significant improvements in shoulder function, low levels of pain, and high return-to-sport rates at long-term follow-up. Revision surgery rates were low. [ABSTRACT FROM AUTHOR]

Background: Due to its significant unilateral predominance, tennis can provoke functional and morphological asymmetries that develop over time and may result in undesired morphological alterations. Hypothesis/Purpose: The goals of this study were a) to assess glenohumeral range of motion and muscular stiffness in young tennis players with and without a history of shoulder pain and b) to examine interlimb asymmetries in these variables in both groups. It was hypothesized that players with a history of shoulder pain would show a reduced glenohumeral internal rotation (IR) and total arc of motion (TAM) and increased stiffness in internal rotator muscles compared to those without shoulder pain. Study Design: Cross-sectional observational study. Methods: Twenty-five participants participated in the study (11 with a history of shoulder pain and 14 without pain). Participants performed stiffness measurements on muscles involved in the main tennis stroke motions alongside range of motion examinations on the dominant (D) and non-dominant (ND) extremities including IR, external shoulder rotation (ER), and TAM. A two-way mixed-design ANOVA analyzed group and limb effects, with effect sizes classified as small, medium, or large. Significant effects were further examined using Bonferroni post hoc tests. Results: There were significant differences between the shoulder pain and no shoulder pain group in the D IR (-3.1º, 6.43%, p = 0.048; effect size [ES] = 0.58) and D TAM (-6.1º, 3.01%, p = 0.024; ES = 0.66). Moreover, significant differences were found between the D and ND extremities in IR in both groups (-9.2º, 14.94%, p < 0.001; ES = -1.72) and TAM in the shoulder pain group (-5.6º, 2,77%, p = 0.038; ES = 0.61). Stiffness measurements showed no significant differences between groups or extremities. Conclusions: Significantly lower values of D IR and TAM and higher IR asymmetries in the shoulder pain group suggest that a deficit in these parameters could be associated with shoulder pain history in junior competitors. Level of Evidence: 2 [ABSTRACT FROM AUTHOR]

Background: Hemiplegic shoulder pain (HSP) is a prevalent clinical manifestation following stroke, often causing considerable discomfort and disability. Various therapeutic approaches have been developed to address HSP. Objectives: This study aimed to compare the effectiveness of HILT versus US therapy in alleviating HSP in stroke patients. Methods: A double-blind randomized controlled trial enrolled stroke patients with HSP within one year post-onset. Participants were randomly assigned to HILT (with sham US) or US therapy (with sham HILT). Both groups received 10-minute sessions of their assigned therapy modality along with daily shoulder range of motion (ROM) exercises 5 times per week over two consecutive weeks. Pain reduction was the primary outcome, with shoulder ROM as secondary outcomes. Results: Thirty patients (11 women, 19 men; mean age: 60.80 ± 11.51 years) were included. After the two-week intervention, significant improvements were observed in pain reduction at rest and during motion in the HILT group, and in pain reduction during motion and shoulder internal rotation in the US group compared to pre-treatment values within each group. However, there was no significant difference between the HILT and US therapy groups in any evaluated parameter. Conclusions: Comparable efficacy was found between HILT and US therapy in reducing pain and improving shoulder ROM for HSP in stroke patients. Both modalities, when combined with shoulder ROM exercises, offer viable options for managing HSP in this population. Further research with larger sample sizes is needed to validate these findings and explore long-term outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Hydroxyapatite deposition disease (HADD) is caused by the presence of hydroxyapatite crystals in periarticular spaces oftentimes leading to inflammation, pain, and decreased range of motion. Case Report: A 40-year-old right hand dominant female presented with three days of atraumatic right shoulder pain. Radiographs of the right shoulder were negative. Computed tomography revealed a hydroxyapatite deposit adjacent to the acromioclavicular joint. The patient was managed with nonsteroidal anti-inflammatory drugs and a referral to orthopedic surgery. Conclusion: Many instances of HADD will not be diagnosed on plain radiographs, and heightened awareness will provide confidence when ordering confirmatory imaging. Management is typically conservative, however, referral to orthopedic surgery is recommended to ensure improvement and to assess the need for more invasive procedures. [ABSTRACT FROM AUTHOR]

Purpose: Shoulder arthroscopic repair of rotator cuff tears with simultaneous treatment of lesions of the long head of the biceps tendon has become increasingly accepted. However, the clinical outcomes between tenotomy and tenodesis remain unclear. This study aimed to compare the efficacy of tenotomy and tenodesis combined with rotator cuff repair in elderly patients with medium-to-massive rotator cuff tears. Patients and Methods: We conducted a retrospective trial of patients aged > 60 years with medium-to-massive rotator cuff tears who underwent arthroscopic rotator cuff repair with tenotomy or tenodesis. This study included 96 patients: 47 in the tenotomy group and 49 in the tenodesis group. At 3 and 6 months after surgery and at the last follow-up, the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score (CS score), anterior shoulder pain (VAS score), elbow flexion strength and supination strength, and complications were recorded. Results: At 3 months postoperatively, ASES score, CS score and strength of elbow flexion of the tenodesis group were significantly better than those of the tenotomy group. In addition, the VAS score is 4.4 ± 1.4 and 3.3 ± 1.3 in the tenodesis and tenotomy respectively (p = 0.039). At the final follow-up, despite no significant statistical differences in ASES scores, CS scores, VAS scores, and flexion strength between the two groups, the variation in the above items in the tenodesis group was statistically lower than that in the tenotomy group. No difference was observed in the rates of complications and revision between the groups. Conclusion: For people over 60 years of age with medium to massive rotator cuff tears, postoperative shoulder function of tenodesis is superior to tenotomy, and functional recovery is relatively more stable after tenodesis than after tenotomy. [ABSTRACT FROM AUTHOR]

Retropharyngeal abscess (RPA) is an uncommon yet potentially life-threatening condition that is more often seen in young children and may be misdiagnosed in adults presenting with atypical features.1 Retropharyngeal abscess results from spread of antecedent upper respiratory tract infection or traumatic inoculation via foreign body ingestion or medical instrumentation. Clinically, RPA may present with fever, pharyngitis, neck pain, and dysphagia. Diagnosis is often confirmed with imaging studies. We present a case of a 66-year-old female with asthma, hypertension, and gastroesophageal reflux disease (GERD) who presented to the emergency department (ED) for evaluation of neck fullness, shoulder pain, dysphagia, and abdominal pain starting less than 24 hours prior to presentation. Computed tomography (CT) revealed a prevertebral/retropharyngeal fluid collection from the odontoid tip to the C4 vertebral body measuring 5.4 x 1.0 x 3.3 centimeters (cm) in size with associated edema at the left neck base extending into the upper chest, suggestive of retropharyngeal abscess. The patient received intravenous (IV) vancomycin and piperacillin/tazobactam and was transferred to a higher level of care for otolaryngologist evaluation. The patient remained stable without airway compromise while in our department. This case underscores challenges in diagnosing atypical presentations of RPA in adults, emphasizing timely recognition to prevent complications. [ABSTRACT FROM AUTHOR]

Objectives: Myofascial trigger points (MTrPs) are potential contributors to shoulder pain and can lead to local ischemia and hypoxia, thus causing pain. Color Doppler ultrasound (US) has been used to examine the vascular environment around MTrPs, but has not been used to examine blood flow impairments in patients with shoulder pain and MTrPs. The reliability of color Doppler US for measuring infraspinatus muscle blood flow also has not been established. This study aimed to investigate differences in blood flow between individuals with and without shoulder pain and the reliability of Doppler US for measuring infraspinatus muscle blood flow. Methods: Forty participants were enrolled, 20 with shoulder pain and MTrPs and 20 without. Color Doppler US examination was performed twice on each participant to measure peak systolic velocity (PSV), end‐diastolic velocity (EDV), resistive index (RI), and pulsatile index (PI) of the infraspinatus muscle. Results: The symptomatic participants had significantly higher PSV (ie, impaired blood flow) than the asymptomatic participants. There were no significant between‐group differences in EDV, RI, and PI. The results also demonstrated good‐to‐excellent intra‐rater reliability for color Doppler US measurements of PSV, EDV, RI, and PI for both groups. Conclusion: This study demonstrated differences in blood flow near MTrPs in the infraspinatus muscle between individuals with and without shoulder pain. It also established good‐to‐excellent reliability of color Doppler US in measuring infraspinatus muscle blood flow. These findings suggest color Doppler US is a useful tool to identify vascular impairments for shoulder pain associated with MTrPs. [ABSTRACT FROM AUTHOR]