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      Guideline for diagnosis and treatment of subacromial pain syndrome : A multidisciplinary review by the Dutch Orthopaedic Association

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          Abstract

          Treatment of “subacromial impingement syndrome” of the shoulder has changed drastically in the past decade. The anatomical explanation as “impingement” of the rotator cuff is not sufficient to cover the pathology. “Subacromial pain syndrome”, SAPS, describes the condition better. A working group formed from a number of Dutch specialist societies, joined by the Dutch Orthopedic Association, has produced a guideline based on the available scientific evidence. This resulted in a new outlook for the treatment of subacromial pain syndrome. The important conclusions and advice from this work are as follows:

          (1) The diagnosis SAPS can only be made using a combination of clinical tests. (2) SAPS should preferably be treated non-operatively. (3) Acute pain should be treated with analgetics if necessary. (4) Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms. (5) Diagnostic imaging is useful after 6 weeks of symptoms. Ultrasound examination is the recommended imaging, to exclude a rotator cuff rupture. (6) Occupational interventions are useful when complaints persist for longer than 6 weeks. (7) Exercise therapy should be specific and should be of low intensity and high frequency, combining eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points (including stretching of the muscles) may be considered. (8) Strict immobilization and mobilization techniques are not recommended. (9) Tendinosis calcarea can be treated by shockwave (ESWT) or needling under ultrasound guidance (barbotage). (10) Rehabilitation in a specialized unit can be considered in chronic, treatment resistant SAPS, with pain perpetuating behavior. (11) There is no convincing evidence that surgical treatment for SAPS is more effective than conservature management. (12) There is no indication for the surgical treatment of asymptomatic rotator cuff tears.

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          Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis.

          The purpose of this study was to compare the diagnostic accuracy of MRI, MR arthrography, and ultrasound for the diagnosis of rotator cuff tears through a meta-analysis of the studies in the literature. Articles reporting the sensitivities and specificities of MRI, MR arthrography, or ultrasound for the diagnosis of rotator cuff tears were identified. Surgical (open and arthroscopic) reference standard was an inclusion criterion. Summary statistics were generated using pooled data. Scatterplots of the data sets were plotted on a graph of sensitivity versus (1 - specificity). Receiver operating characteristic (ROC) curves were generated. Sixty-five articles met the inclusion criteria for this meta-analysis. In diagnosing a full-thickness tear or a partial-thickness rotator cuff tear, MR arthrography is more sensitive and specific than either MRI or ultrasound (p 0.05). Summary ROC curves for MR arthrography, MRI, and ultrasound for all tears show the area under the ROC curve is greatest for MR arthrography (0.935), followed by ultrasound (0.889) and then MRI (0.878); however, pairwise comparisons of these curves show no significant differences between MRI and ultrasound (p > 0.05). MR arthrography is the most sensitive and specific technique for diagnosing both full- and partial-thickness rotator cuff tears. Ultrasound and MRI are comparable in both sensitivity and specificity.
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            Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests.

            To compile and critique research on the diagnostic accuracy of individual orthopaedic physical examination tests in a manner that would allow clinicians to judge whether these tests are valuable to their practice. A computer-assisted literature search of MEDLINE, CINAHL, and SPORTDiscus databases (1966 to October 2006) using keywords related to diagnostic accuracy of physical examination tests of the shoulder. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool was used to critique the quality of each paper. Meta-analysis through meta-regression of the diagnostic odds ratio (DOR) was performed on the Neer test for impingement, the Hawkins-Kennedy test for impingement, and the Speed test for superior labral pathology. Forty-five studies were critiqued with only half demonstrating acceptable high quality and only two having adequate sample size. For impingement, the meta-analysis revealed that the pooled sensitivity and specificity for the Neer test was 79% and 53%, respectively, and for the Hawkins-Kennedy test was 79% and 59%, respectively. For superior labral (SLAP) tears, the summary sensitivity and specificity of the Speed test was 32% and 61%, respectively. Regarding orthopaedic special tests (OSTs) where meta-analysis was not possible either due to lack of sufficient studies or heterogeneity between studies, the list that demonstrates both high sensitivity and high specificity is short: hornblowers's sign and the external rotation lag sign for tears of the rotator cuff, biceps load II for superior labral anterior to posterior (SLAP) lesions, and apprehension, relocation and anterior release for anterior instability. Even these tests have been under-studied or are from lower quality studies or both. No tests for impingement or acromioclavicular (AC) joint pathology demonstrated significant diagnostic accuracy. Based on pooled data, the diagnostic accuracy of the Neer test for impingement, the Hawkins-Kennedy test for impingement and the Speed test for labral pathology is limited. There is a great need for large, prospective, well-designed studies that examine the diagnostic accuracy of the numerous physical examination tests of the shoulder. Currently, almost without exception, there is a lack of clarity with regard to whether common OSTs used in clinical examination are useful in differentially diagnosing pathologies of the shoulder.
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              Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanical results.

              There are significant differences in incidence of cosmetic deformity and load to tendon failure between biceps tenotomy versus tenodesis for the treatment of long head of the biceps brachii (LHB) tendon lesions which are supported by the evidence-based strengths and weaknesses of each procedure in the literature. PubMed, Embase, and Cochrane databases were searched for eligible clinical and biomechanical articles relating to biceps tenotomy or tenodesis from 1966 to 2010. Keywords were biceps tenotomy, biceps tenodesis, long head of the biceps brachii, and Popeye sign. All relevant studies were included based on study objectives, and excluded studies consisted of abstracts, case reports, letters to the editor, and articles without outcome measures. All articles reviewed were of level IV evidence. Combined results from reviewed papers on the differences between LHB tenotomy vs tenodesis demonstrated a higher incidence of cosmetic deformity in patients treated with biceps tenotomy. Complications were similar for each treatment, with a higher likelihood of bicipital pain associated with tenodesis. Lack of high levels of evidence from prospective randomized trials limits our ability to recommend one technique over another. This review demonstrated a higher incidence of cosmetic deformity in patients treated with biceps tenotomy compared with tenodesis, with an associated lower load to tendon failure. However, there was no consensus in the literature regarding the use of tenotomy vs. tenodesis for LHB tendon lesions due to variable results and methodology of published studies. Individual patient factors and needs should guide surgeons on whether to use tenotomy or tenodesis. There is a great need for future studies with high levels of evidence, control, randomization, and power, with well-defined study variables, to compare biceps tenotomy and tenodesis for the treatment of LHB tendon lesions. Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.
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                Author and article information

                Journal
                Acta Orthop
                Acta Orthop
                ORT
                Acta Orthopaedica
                Informa Healthcare
                1745-3674
                1745-3682
                June 2014
                16 June 2014
                : 85
                : 3
                : 314-322
                Affiliations
                1Netherlands Orthopedic Society
                2Royal Netherlands Association of Physical Therapy
                3Netherlands Association of General Practitioners
                4Netherlands Society of Rehabilitation Medicine
                5Netherlands Association of Occupational Medicine
                6Netherlands Society of Radiology
                Author notes
                Article
                ORT_A_920991_O
                10.3109/17453674.2014.920991
                4062801
                24847788
                35156f41-4470-4df8-be62-8207b6cf34e8
                Copyright: © Nordic Orthopaedic Federation

                This is an open-access article distributed under the terms of the CC-BY-NC-ND 3.0 License which permits users to download and share the article for non-commercial purposes, so long as the article is reproduced in the whole without changes, and provided the original source is credited.

                History
                : 23 January 2014
                : 04 March 2014
                Categories
                Guideline and Oncology

                Orthopedics
                Orthopedics

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