Sexual Activities as Risk Factors of Rotator Cuff Lesions: A Prospective Cohort Study

Abstract

The aim of this study was to analyze the occurrence of rotator cuff impingement due to reduction of subacromial space height during complex shoulder motion to determine safety of sexual activities. The hypothesis was that such activities could be deleterious if not performed with precaution. To use a patient-specific 3D measurement technique coupling medical imaging and optical motion capture to evaluate the safety of various sexual positions according to subacromial compression. Descriptive laboratory study. A volunteer couple underwent Magnetic Resonance Imaging (MRI) and motion capture of their shoulders. Five common active and passive sexual positions were evaluated. Significant differences in subacromial space height were observed between the different performed actions. All active sexual positions requiring important pressure on the hands or elbows (e.g., scorpio) or weight lifting (e.g., superman) caused subacromial impingement. No subacromial impingement was however observed during passive sexual activities (e.g., basset hound). This study indicates that some sexual positions could potentially place the rotator cuff at risk. Such high-tech investigation shows promise in the areas of cause, intervention and education. The present findings may assist health professionals in providing them with preventive measures and is highly relevant for decision-making regarding health promoting initiatives.

Full text

Vol.:(0123456789)
Sexuality and Disability (2018) 36:305–311
https://doi.org/10.1007/s11195-018-9543-y
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ORIGINAL PAPER
Sexual Activities asRisk Factors ofRotator Cu Lesions:
AProspective Cohort Study
AlexandreLädermann1,2,3,4 · GrégoryCunningham1,2,3,4· SylvainChagué5·
CaeciliaCharbonnier5
Published online: 30 October 2018
© The Author(s) 2018
Abstract
The aim of this study was to analyze the occurrence of rotator cuff impingement due to
reduction of subacromial space height during complex shoulder motion to determine
safety of sexual activities. The hypothesis was that such activities could be deleterious if
not performed with precaution. To use a patient-specific 3D measurement technique cou-
pling medical imaging and optical motion capture to evaluate the safety of various sexual
positions according to subacromial compression. Descriptive laboratory study. A volun-
teer couple underwent Magnetic Resonance Imaging (MRI) and motion capture of their
shoulders. Five common active and passive sexual positions were evaluated. Significant
differences in subacromial space height were observed between the different performed
actions. All active sexual positions requiring important pressure on the hands or elbows
(e.g., scorpio) or weight lifting (e.g., superman) caused subacromial impingement. No sub-
acromial impingement was however observed during passive sexual activities (e.g., basset
hound). This study indicates that some sexual positions could potentially place the rotator
cuff at risk. Such high-tech investigation shows promise in the areas of cause, intervention
and education. The present findings may assist health professionals in providing them with
preventive measures and is highly relevant for decision-making regarding health promoting
initiatives.
Keywords Shoulder pathology· Rotator cuff tear· Tendinopathy· Subacromial
impingement· Sexual activity· Kinematics· Biomechanics· 3D simulation· Switzerland
* Alexandre Lädermann
alexandre.laedermann@gmail.com
1 Division ofOrthopaedics andTrauma Surgery, La Tour Hospital, Avenue J.-D. Maillard 3,
1217Meyrin, Switzerland
2 Faculty ofMedicine, University ofGeneva, Geneva, Switzerland
3 Division ofOrthopaedics andTrauma Surgery, Department ofSurgery, Geneva University
Hospitals, Geneva, Switzerland
4 Division ofOrthopaedics andTrauma Surgery, Hirslanden La Colline, Geneva, Switzerland
5 Medical Research Department, Artanim Foundation, Geneva, Switzerland
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Introduction
Tears of the rotator cuff are a frequent and a well-known cause of chronic pain and dys-
function in the shoulder [1]. Their aetiologies in non-traumatic situations are controver-
sial, with two main theories described: an extrinsic mechanism, also called subacromial
impingement, where symptoms are caused by compression of the rotator cuff [2], and
an intrinsic one, where symptoms are thought to result from overload on degenerating
rotator cuff tendons [3]. The authors of the present study have noted other alarming risk
factors in recent publications that may impede with general quality of life. Indeed, it has
been proved that almost all enjoyable activities (i.e., sports [4], good food associated to
hypercholesterolemia [5], alcohol [6] or tobacco [7]) are deleterious for the rotator cuff.
Sexual activity is another known factor of emotional happiness [8]. However, no such
association has been established with shoulder injuries yet. To rule out a ‘worst case
scenario’, the authors investigated if the latter activity was also associated with rotator
cuff overload in order to promote, if required, adequate injury prevention. This issue
remaining rarely discussed and very limited objective data being available to propose
recommendations, they felt the necessity to fill this gap. Simulating dynamically subac-
romial impingements during activities of daily living is challenging. This requires accu-
rate 3D reconstruction of the shoulder bones, kinematics estimation of the joint dur-
ing complex shoulder motion and evaluation of impingement using the subject-specific
3D models and kinematics. Fortunately, the authors previously developed and validated
in different studies all the necessary tools to perform such challenging simulation [4,
9–11].
The aim of this study was to analyze the occurrence of rotator cuff impingement dur-
ing complex shoulder motion using an invivo technique combining optical motion cap-
ture and magnetic resonance imaging (MRI) to determine safety sexual activities for
men. The hypothesis was that such activities could be deleterious for shoulders if not
performed with precaution.
Methods
Subjects
This study was a prospective trial carried out on two healthy right-handed volunteers
(one female, one male) that did not report previous shoulder injury or surgery. The
age, weight, height and body mass index of the two subjects were 39 and 31 years,
161 and 180cm, 52 and 80kg, and 22.5 and 24.7 kg/m2, respectively. The dominant
arm was used throughout testing. Young healthy subjects were chosen for two reasons:
(1) patients presenting symptomatic rotator cuff tears are becoming younger [1] and
are therefore sexually more active; (2) certain sexual positions tested being at risk or
physically demanding, inclusion of healthy subjects was hence preferable to avoid any
incident during motion capture. Exclusion criteria included previous pathology or sur-
gery of the shoulders, any psychiatric condition such as obsessive–compulsive disor-
der (OCD, DSM-IV Code 300.3) or psycho-physiological sexual dysfunction. The latter
was based on medical history collection, only. The study was approved by our hospital’s
institutional review board (AMG-12.18).
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Study Variables
The outcome of interest was the impact of common sexual positions on subacromial space
height.
3D Reconstruction, Kinematic Recording andModelling
The volunteers underwent an MRI performed with a 1.5 T HDxT system (General Elec-
tric Healthcare, Milwaukee WI, USA). A dedicated shoulder surface coil was used. Three
3D MRI volumes were acquired: a cosmic 3D fast gradient echo sequence with fat satu-
ration (section thickness 1.8 mm; no gaps; TR/TE ms 6.1/3.0; flip angle 45°) capturing
from the acromion to approximately the mid-part of the scapula, a cosmic 3D fast gradient
echo sequence (section thickness 4mm; no gaps; TR/TE ms 5.7/2.8) capturing from the
acromion to approximately the mid-shaft of the humerus, and a lava 3D fast gradient echo
sequence (section thickness 5.2mm; no gaps; TR/TE ms 3.7/1.7) capturing from the acro-
mion to the elbow.
The MR images were manually segmented and a virtual 3D model of the shoulder com-
plex was reconstructed using Mimics software (Materialize NV, Leuven, Belgium). For
each volunteer, patient-specific 3D models of the shoulder bones (humerus, scapula, clavi-
cle and sternum) were thus obtained.
The next step was motion recording. The two volunteers were equipped with a dedi-
cated shoulder markers protocol [9], including 69 spherical retroreflective markers placed
directly onto the skin using double sided adhesive tape.
Then, after appropriate preliminaries, the two volunteers were asked to perform five
common sexual positions (Fig.1) divided into the following categories: “man-on-top” such
as missionary and scorpio, “woman-on-top” such as watering can, “doggy style” such as
basset hound and “standing” such as superman. A mattress was utilized when needed.
The female and male volunteers were asked to simulate each sexual position three times.
Motion was recorded using a Vicon MXT40S motion capture system (Vicon, Oxford Met-
rics, UK) consisting of 24 cameras sampling at 120Hz.
Fig. 1 The five common sexual positions used in this study. In all images, the woman is represented in yel-
low and the man in green (Color figure online)
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Shoulder kinematics were computed from the recorded markers’ trajectories using
a validated biomechanical model [9] which accounted for skin motion artifacts. The
model was based on a patient-specific kinematic chain using the 3D models recon-
structed from participants’ MRI scan data and a global optimization algorithm with
loose constraints on joint translations (accuracy: translational error < 3mm, rotational
error < 4°). As a result, the motion of the subject’s shoulder 3D models could be visual-
ized at each point of the movement (see Fig.2).
Evaluation ofSubacromial Space Height
Subacromial space height was assessed for all tested positions during sexual activity by
measuring the minimum distance between the inferior acromial surface and the humeral
head surface [10]. This distance was calculated in 3D based on the simulated bones
models positions and was reported in millimeters. A color scale was used to map the
variations of distance on the scapula surface, with red denoting the zone of minimum
distance and other colors denoting the areas of increased distance (Fig.2). Given the
thickness of the potential impinged tissues, subacromial impingement was considered
when the computed acromio-humeral distance was < 6mm, as suggested in previous
studies [12, 13].
Statistical Analysis
For each shopping angle and sexual position, we calculated the minimal subacromial
space height for the three trials performed. The mean and standard deviation (SD) were
then computed for each positions.
Fig. 2 Visualization of the acro-
mio-humeral distance during the
60° shopping angle. Left: joint
pose computed by motion cap-
ture. Right: zoom in the shoulder.
The colors represent the vari-
ations of distance between the
acromion and humeral head. Red
denotes the zone of minimum
distance. Note: the humerus is
not shown for clarity (Color
figure online)
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Results
Results are summarized in Table1. No shoulder pathologies were noticed on MRI. Mini-
mal subacromial height ranged between 0.91mm and 6.2mm for the sexual positions.
The least favorable sexual activity with respect to subacromial space height was during the
practice of the scorpio position.
Discussion
Subacromial impingement and superior rotator cuff pathologies are associated with dys-
function and pain related to the upper extremity [14]. Physicians and probably patients
wonder about the risk related to sexual activities. Presently, surgeons or other healthcare
professionals lack scientifically validated information on appropriate answers or guide-
lines and are therefore unable to provide specific instructions to patient’s inquiries. The
hypothesis of this study was confirmed as it demonstrated that certain positions during
sexual activities might participate to the development of rotator cuff degeneration. The
study revealed that five activities decreased the subacromial space, participating in tendon
lesions by friction on the undersurface of the acromion. As shoulder pathologies represent
a paramount socioeconomic burden on the society and a cause of great distress to patients,
the present findings are highly relevant. Indeed, sexual activities, if not performed with
temperance, seem to be deleterious and may play a role in the dramatic surge in overall
incidence rate in rotator cuff disease that has been recently reported [1].
The results of the present simulation seem to indicate that male or female can, in case
of pain during intercourse, safely adopt a more passive attitude. Indeed, as expected, the
watering can and the basset hound sexual positions required less stress on the rotator cuff
and could be therefore considered as safer.
Strengths andLimitations
This prospective study was the first to precisely analyze the impact of sexual positions on
subacromial space height. The information helps the caregiver to advice patients suffering
from rotator cuff pathologies. The findings are relevant and may explain the dramatic surge
in overall incidence rate in rotator cuff disease [1]. Moreover, patient selection was strict
with exclusion of all conditions (previous pathology or surgery, obsessive–compulsive dis-
order, etc.) that might affect the results. However, there were several limitations that war-
rant discussion. First, only two patients were tested due to the complexity of analysis and
Table 1 Minimal subacromial
space height (mm) for each
position (n = 3)
Data are reported for the male participant performing three trials for
each position
Man’s sexual positions Mean SD
Missionary 1.27 0.03
Scorpio 0.91 1.06
Watering can 6.1 0.22
Basset hound 6.2 0.17
Superman 1.76 1.60
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the sensitive nature of the experiment or delicate topic in which the subjects were asked
to participate. This prevents us from verifying if similar patterns of subacromial impinge-
ments are observed in other individuals and correlating the results to patient-specific anat-
omy. Second, the body mass index of the two patients reflects reasonably healthy patients.
Consequently, this study may underestimate the stress on rotator cuff generated by such
activities in patients with higher body mass index. Third, the accuracy of the kinematics
computation from motion capture data could be criticized. Gleno-humeral orientation and
translation errors were respectively within 4° and 3mm for each anatomical plane [9],
which is acceptable for clinical use in the study of shoulder pathology. Fourth and last, we
based our analysis of subacromial impingement on acromio-humeral distance [15]. Never-
theless, previous theories about acromio-humeral distance have been questioned. Indeed, it
is unclear if the height of the subacromial space really plays a role, as it is now considered
as a neo-articulation—the permanent contact between the humeral head and coraco-acro-
mial arch during elevation of the arm being normal [16]. There is also growing evidence
suggesting that distinct scapular morphologies and not simply subacromial impingement
may accelerate the underlying degenerative process [17]. Despite these potential limita-
tions, we do believe in the validity of the conclusions of this preliminary study.
Conclusion
This study indicates that some sexual positions could potentially place the rotator cuff at
risk. Such high-tech investigation shows promise in the areas of cause, intervention and
education. The present findings may assist health professionals in providing them with pre-
ventive measures and is highly relevant for decision-making regarding health promoting
initiatives.
Author Contributions AL designed the study and wrote the manuscript. GJC critically reviewed the study
proposal and served as scientific advisors. SC collected and analysed the data and provided and cared for
study patients. CC collected and analysed the data and wrote the manuscript.
Compliance with Ethical Standards
Conict of interest The authors declare that they have no conflict of interest.
Ethical/IRB Approval Hospital’s institutional review board (AMG-12.18).
Informed Consent Obtained from the volunteers.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 Interna-
tional License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution,
and reproduction in any medium, provided you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons license, and indicate if changes were made.
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