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Janda's Upper Crossed Syndrome. Reprinted, with permission, from Page et al, 2010, Assessment and Treatment of Muscle Imbalance: The Janda Approach (Champaign, IL: Human Kinetics).  

Janda's Upper Crossed Syndrome. Reprinted, with permission, from Page et al, 2010, Assessment and Treatment of Muscle Imbalance: The Janda Approach (Champaign, IL: Human Kinetics).  

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Subacromial impingement is a frequent and painful condition among athletes, particularly those involved in overhead sports such as baseball and swimming. There are generally two types of subacromial impingement: structural and functional. While structural impingement is caused by a physical loss of area in the subacromial space due to bony growth o...

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... Janda suggested that subacro- mial impingement results from a characteristic pat- tern of muscle imbalance including weakness of the lower and middle trapezius, serratus anterior, infra- spinatus, and deltoid, coupled with tightness of the upper trapezius, pectorals and levator scapula. 1 This pattern is often referred to as part of Janda's "Upper Crossed Syndrome." (See Figure 1) While structural impingement sometimes requires surgery to alleviate pain, functional instability requires the implementation of precise therapeutic exercises Imbalances or deficits in muscular strength and activation levels can lead to functional impinge- ment. Both glenohumeral and scapulothoracic mus- cle imbalances can contribute to shoulder complex dysfunction. ...

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... NME has effects on muscle activation patterns and biomechanics of the surrounding joint musculature [50]. The strength and coordination of muscle exercises involved in NME may be the reason for the increase in AROM, as the shoulder complex relies on muscles to provide dynamic stability and flexibility for AROM [51]. However, evidence for NME is lacking at ROM in FS, and no previous study was found. ...
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Abstract Background and objectives Frozen shoulder (FS) is characterized by pain and significant loss of active and passive shoulder motion. Strengthening exercises are among the standard exercises used for FS. Neuromuscular exercise (NME) effectively improved pain and the range of motion in shoulder. However, no prior research has looked into the effects of NME compared to strengthening exercises in FS rehabilitation. The aim of the present study was to evaluate the effects of NME compared to strengthening exercises on pain and active range of motion (AROM) in individuals with idiopathic frozen shoulder. Methods Forty individuals with idiopathic frozen shoulder were randomly assigned to either the experimental group (NME with regular physical therapy, n = 20) or the control group (strengthening exercises with regular physical therapy, n = 20). In both groups, the interventions were performed once a day, 5 days a week for 8 weeks. Pain scores on the visual analogue scale (VAS) and AROM of the shoulder were assessed at baseline and after the 8-week treatment. The primary analysis was the group × time interaction. Results Two-by-two mixed analysis of variance (ANOVA) revealed a significant group × time interaction for VAS (F = 29.67; p
... The shift of the humeral head center causes a functional narrowing of the subacromial space [38]. This functional narrowing of the subacromial space has been directly linked to glenohumeral instability in overhead athletes aged < 35 years old [39,40]. The results of the meta-analysis in this variable showed a statically significant increment after the intervention [27,29]. ...
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Background: To evaluate the effectiveness of conservative therapy in range of movement (ROM), strength, pain, subacromial space and physical function, in overhead athletes with glenohumeral internal rotation deficit (GIRD). Methods: A systematic review and meta-analysis was designed, and the protocol was registered in PROSPERO (CRD42021281559). The databases searched were: PubMed, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, Web of Science and SCOPUS. Randomized controlled trials (RCTs) involving conservative therapy applied in overhead athletes with GIRD were included. Two independent assessors evaluated the quality of the studies with the PEDro scale, and with the Cochrane Risk-of-Bias tool. The overall quality of the evidence was assessed using GRADE. Data on outcomes of interest were extracted by a researcher using RevMan 5.4 software. Estimates were presented as standardized mean differences (SMD) with 95% confidence intervals (CIs). Results: A total of eleven studies involving 514 overhead athletes were included in the systematic review; of these 8 were included in the meta-analysis. The methodological quality of the included RCTs ranged from high to low. Conservative therapy showed significant improvements in internal rotation, adduction, physical function and subacromial space. Conclusions: Conservative therapy based on stretch, passive joint and muscular mobilizations can be useful to improve the internal rotation and adduction ROM, subacromial space, and physical function of the shoulder in overhead athletes with glenohumeral internal rotation deficit.
... Tight control over gene expression is associated with regulatory mechanisms in cells, which can be either inducible or epigenetic [125]. In addition to biochemical and molecular signals and pathways, epigenetic mechanisms are involved in the initiation, progression, and regulation of inflammatory responses within injured tissues [146]. During asymptomatic tendinopathies, the tenocytes express the TREM1 molecule and function, such as immune cells, which in turn are regulated by high mobility group box 1 protein (HMGB1) and the receptor for advanced glycation end products (RAGE), which mediate sterile inflammatory responses [125]. ...
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... The hallmark of our findings was the decrease in minimal vertical AHD, whereby the causes encompass loss of soft tissue contents in the subacromial space (eg, rotator cuff tendon tear), early or excessive upward migration of the humeral head, and delayed or inadequate medial rotation of the scapula. 18 In our database, rotator cuff tendon tears were present in <10% of the patients and less likely to be the cause of reduced minimal vertical AHD. The contribution from the latter 2 causes might not be differentiable in our model because the motion metrics were based on reciprocal movements of the greater tuberosity against the acromion. ...
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Objectives : To explore the subacromial motion metrics in patients with and without subacromial impingement syndrome (SIS) and to investigate whether the abnormality was associated with rotator cuff pathologies. Design This cross-sectional observational study used dynamic quantitative ultrasound imaging for shoulder joint assessment. Setting Outpatient rehabilitation clinic. Participants Individuals with SIS on at least one shoulder (n=32) and asymptomatic controls (n=32). Interventions Not applicable. Main Outcome Measures Frame-by-frame, the humeral greater tuberosity against the lateral edge of the acromion was traced to obtain the minimal vertical acromiohumeral distance (AHD). The rotation angle and radius of the humerus were computed using the least-squares curve fitting method. Results Approximately two-thirds of the shoulders with SIS did not have any sonographically identifiable rotator cuff pathologies. There was a consistent trend of non-significantly increased humeral rotation angles in painful shoulders. The generalized estimating equation demonstrated that the decreased minimal vertical AHD was associated with painful subacromial impingement (beta coefficient of -0.123 cm, 95% confidence interval [CI], -0.199 to -0.047). The area under the curve for the minimal vertical AHD to discriminate painful/impinged shoulders ranged from 0.624 to 0.676. The increased rotation angle (beta coefficient of 10.516°; 95% CI, 3.103-17.929) and decreased rotation radius (beta coefficient of -2.903 cm; 95% CI, -5.693 to -0.111) were shown to be significantly related to the presence of supraspinatus tendinopathy. Conclusions Shoulders with SIS were characterized by a decreased minimal vertical AHD during dynamic examination. Abnormal subacromial metrics can develop in patients with mild (or no) rotator cuff pathologies. More prospective cohort studies are warranted to investigate the changes in subacromial motion metrics in populations at risk for painful/impinged shoulders.
... Pain, weakness, and loss of movement at the shoulder due to irritation of the soft tissues as they pass underneath the acromion are due to the inflammation of tendons, bursa, and joint capsule [5,22]. Plain X-ray is unable to diagnose soft tissue-related abnormalities; however, ultrasound is the modality of choice to observe cortical parts of the bone as well as soft tissue-related abnormalities [23]. ...
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Background Shoulder impingement syndrome is the painful entrapment of the soft tissues between the acromion and the humeral head. The severity of shoulder impingement could be graded according to the limitation of shoulder joint moment. The reliability of sonographic findings in the grading of shoulder impingement severity grading is required to be evaluated by the consistency of findings between the observers. Purpose To assess the interobserver agreement in the sonographic severity grading of shoulder impingement syndrome with the help of a ratio between acromion-to-greater tuberosity distance in the abduction and neutral arm position. Material and methods Patients were examined by two independent observers in the coronal approach with neutral arm position. Acromion-to-greater tuberosity distance was measured in abduction and neutral shoulder position. The ratios of the distances in the abduction and neutral position were calculated to grade the severity of shoulder impingement syndrome. Results A total of 78 shoulders were included in this study. A strong agreement was found for the grading of shoulder impingement severity grading between the two independent observers with Kappa value of 0.94. And correlation between the results of the two observers for the severity grading of shoulder impingement syndrome was significant at 0.01 level. Conclusion Severity grading of the shoulder impingement syndrome was performed based on the ratio of acromion-to-greater tuberosity distance in abduction and neutral arm position. However, the sonographic findings were consistent and a strong interobserver agreement was seen in this sonographic severity grading.
... Shoulder impingement is an umbrella term malady that involves extrinsic or intrinsic forces on the multiple constructs that comprise shoulder motion, accounting for 44-65% of shoulder complaints. 2 Specifically, subacromial impingement refers to a narrowing of the subacromial space, a common issue with overhead athletes. Shoulder range of motion involves static stabilizers such as the glenoid labrum and joint capsule, but also dynamic stabilizers such as the rotator cuff tendons and periscapular muscles. ...
... contrast to tightness of upper trapezius, pectorals, and levator scapula. 2 Subacromial impingement featuring this agonist and antagonist scapular function imbalance, has shown to cause compression of the subacromial space and alterations in shoulder kinematics and muscle activation. 3 Furthermore, postural patterns which create a scapula in protraction and anterior tilt is suggested to increase compression of the subacromial space. ...
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Overuse injuries affect persons of all ages and physical participation levels. These injuries involve repetitive overload causing damage and pain to various joints, affecting performance and ability to continue participation. Even when an injury diagnosis is apparent, functional assessment is useful in discovering the underlying mechanism.
... In this regard, Shoulder Impingement Syndrome (SIS) is one of the most common problems in overhead motions, sporting activities, daily life, and many jobs. SIS is the most common chronic shoulder complication in athletes younger than 35 with overhead motions [3,4]. People with SIS have shown pain and reduced shoulder function. ...
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Purpose: Sub-acromial impingement syndrome (SAIS) is one of the most common causes of shoulder pain and affects shoulder joint proprioception. The closed kinetic chain (CKC) exercises with sling are more effective and safer than open kinetic chain (OKC) exercises. This study aimed to compare the effectiveness of OKC and total-body resistance exercises (TRX) sling training on shoulder joint position sense (JPS) in overhead athletes with shoulder impingement syndrome (SIS). Methods: This article was a randomized control trial (RCT) study conducted in Kerman City, Iran, in 2019. The research sample included 33 overhead athletes with SIS who were randomly classified into three groups: OKC, sling, and control groups. Joint position sense (JPS) was evaluated in external rotation (ER), internal rotation (IR), and abduction of the dominant arm in the target angle concerning the shoulder range of motion with the Leighton flexometer. The obtained data were analyzed using the analysis of covariance (ANCOVA). Results: The post-intervention results showed that a significant difference was observed between groups (ER, P<0.001; IR, P<0.001; abduction P<0.001). The change in the sling exercises group was significantly higher in ER, and IR, except abduction JPS than in OKC (P=0.001, P=0.001, P=0.235, respectively) and control groups (P<0.001, P<0.001, P<0.001, respectively). Change in the OKC group was significantly higher in ER, IR, and abduction JPS (P=0.001, P=0.019, P<0.001, respectively) than in the control group. The OKC and sling exercise improved the shoulder JPS of overhead athletes with SIS. Conclusion: The study results showed that the sling exercises were more effective than the OKC exercise for the shoulder JPS because these exercises were CKC and performed on an unstable level.
... Fung et al. (2010) showed that fatigue might cause increased stiffness and decreased hysteresis at low-and mid-levels, mostly due to changes in fibres recruitment in damaged and undamaged fibres. The increase in stiffness of the pectoralis major might be related to repetitive elevation during climbing causing tightness of this muscle (Page, 2011). Furthermore, a higher stiffness of the deltoid posterior and infraspinatus could be a result of climbing movement pattern caused by positioning of holds on the wall to horizontal movements (Reinold et al., 2004). ...
Article
This study aimed to investigate the acute effect of repeated climbing actions on functional and morphological measures of the shoulder girdle. Fifteen male indoor climbers participated in this study. All the climbers declared route level 6a+, as the best climbing grade (French climbing grade scale). Functional (range of motion - ROM and muscle strength), and morphological measurements (muscle/tendon stiffness and thickness) after a repeated climbing exercise protocol were analyzed. The ROM and muscle strength showed significant decreases from baseline to Immediate-Post (IA) as well as significant increases from IA to 1h-Post for all movements (p ≤.001 for all). Muscle stiffness showed significant increases from baseline to IA after as well as significant decreases from IA to 1h-Post for all muscles (p ≤.001 for all). However, thickness showed significant increases from baseline to IA for supraspinatus tendon and muscle thickness and occupation ratio (p ≤.001 for all), while a significant decrease was observed in acromiohumeral distance (p ≤.001). Significant decreases from IA to 1h-Post were found for muscles/tendons and occupation ratio (p ≤.001 for all), while a significant increase for AHD (p ≤.001). Our data demonstrated acute alterations in tendon thickness due to acute signs of implement symptom in climbers.
... 2,3 Gleno-humeral and scapulo-thoracic muscular imbalance and differences in patterns of activation and their level of contributions may contribute for impingement syndrome. 4 It was observed that impingement of shoulder may cause reduction in subacromial space which is measured by quantifying acromio-humeral distance (AHD) (linear distance between the head of the humerus and the acromion) using ultrasonography. 5,6 There are wide variety of methods to treat shoulder impingement syndrome that focus on decrease pain, functional disability and improve mobility of patients. ...
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Kinesio-taping is widely used in sports rehabilitation for prevention and treatment of sports-related injuries. The role of Kinesio-taping has recently received renewed interest in patients with shoulder problems like shoulder impingement or rotator cuff tendinopathy. This pilot study was undertaken to check the effect of therapeutic kinesio-taping versus placebo kinesio-taping on shoulder pain, acromio-humeral distance (AHD), mobility and disability in patients with shoulder impingement syndrome. 8 patients diagnosed with shoulder impingement syndrome were included in the study and they were allocated into the experimental and control group. The patients in experimental group received ultrasound therapy for 8 minutes followed by application of therapeutic kinesio-taping and in control group patients received ultrasound therapy for 8 minutes followed by application of placebo kinesio-taping. Outcome measure were pain intensity by NPRS, shoulder range of motion by goniometry, acromio-humeral distance (AHD) using ultrasonography and functional disability by SPADI assessed at baseline, immediate after taping application and 3 days post intervention. Data analyzed with Kruskal-Wallis H test and p value less than 0.05 consider as significant. Therapeutic kinesio-taping group showed significant change in AHD (p=0.04), pain. (p=0.0001), shoulder range of motion including abduction (p=0.04), internal rotation (p=0.001) and functional disability (0.04), whereas placebo kinesio-taping showed no significant improvement in outcomes. Therapeutic kinesio-taping found to be effective in increasing AHD, range of motion, decreasing pain and functional disability when compare with placebo kinesio-taping. It can be used as adjunct treatment option in patient with shoulder impingement.
... The literature emphasizes the importance of RC muscles in maintaining the SAS via depressing the humeral head to counteract the deltoid action to prevent superior migration of the humeral head (Leong, et al., 2012;Page, 2011). The supraspinatus is the most commonly involved muscle in SIS, and it is considered to be of the greatest practical importance among the RC muscles (Ellis & Mahadevan, 2013). ...
Article
We aimed to investigate the relationships of isometric and eccentric shoulder abduction strength with acromiohumeral distance and supraspinatus tendon thickness based on the disease stage in patients with subacromial impingement syndrome. Eighty-two patients with subacromial impingement syndrome were assessed. Acromiohumeral distance and supraspinatus tendon thickness were measured using ultrasonography. Isometric and eccentric shoulder abduction strength were measured with a hand-held dynamometer. Spearman’s correlation coefficients were calculated. Isometric (rho = 0.428, p=.021) and eccentric (rho = 0.487, p=.007) shoulder abduction strength showed moderate correlations with acromiohumeral distance in patients with acute symptoms (n = 29). There was no relationship between acromiohumeral distance and abduction strength in patients with chronic symptoms (n = 53) (p>.050). Supraspinatus tendon thickness showed no significant correlation with abduction strength (p>.050). These findings suggest that the relationship between acromiohumeral distance and abduction strength differs according to disease stage. However, supraspinatus tendon thickness was not correlated with abduction strength regardless of disease stage. In patients with acute subacromial impingement syndrome symptoms increasing shoulder abduction strength may be a potential strategy to improve acromiohumeral distance.