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No di e ence in long- e m de elopmen o o a o
cu up u e and muscle olumes in impingemen
pa ien s wi h o wi hou decomp ession
Saa a Ke ola, Janne Leh inen, Pe a Elo, Seppo Ko elainen, Heini Huh ala &
Ilkka A nala
To ci e his a icle: Saa a Ke ola, Janne Leh inen, Pe a Elo, Seppo Ko elainen, Heini Huh ala &
Ilkka A nala (2016) No di e ence in long- e m de elopmen o o a o cu up u e and muscle
olumes in impingemen pa ien s wi h o wi hou decomp ession, Ac a O hopaedica, 87:4,
351-355, DOI: 10.1080/17453674.2016.1177780
To link o his a icle: h p://dx.doi.o g/10.1080/17453674.2016.1177780
© 2016 The Au ho (s). Published by Taylo &
F ancis on behal o he No dic O hopedic
Fede a ion.
Published online: 27 Jun 2016.
Submi you a icle o his jou nal
A icle iews: 389
View ela ed a icles
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Ac a O hopaedica 2016; 87 (4): 351–355 351
No di e ence in long- e m de elopmen o o a o cu up u e
and muscle olumes in impingemen pa ien s wi h o wi hou
decomp ession
A andomized MRI s udy o 140 pa ien s
Saa a KETOLA 1, Janne LEHTINEN 2, Pe a ELO 1, Seppo KORTELAINEN 3, Heini HUHTALA 4, and Ilkka ARNALA 3
1 Coxa Hospi al o Join Replacemen , Tampe e; 2 Ha anpää Hospi al, Tampe e; 3 Kan a-Häme Cen al Hospi al, Hämeenlinna; 4 Uni e si y o Tampe e,
Tampe e, Finland.
Co espondence: [email p o ec ed]
Submi ed 2015-11-02. Accep ed 2016-03-01.
© 2016 The Au ho (s). Published by Taylo & F ancis on behal o he No dic O hopedic Fede a ion. This is an Open Access a icle dis ibu ed unde he e ms
o he C ea i e Commons A ibu ion-Non-Comme cial License (h ps://c ea i ecommons.o g/licenses/by-nc/3.0)
DOI 10.1080/17453674.2016.1177780
Backg ound and pu pose — A h oscopic ac omioplas y is s ill
commonly used in he ea men o shoulde impingemen syn-
d ome, e en hough i s bene i s a e ques ioned; andomized
con olled s udies ha e no shown any bene i s when compa ed
o non-ope a i e ea men . In his andomized s udy, we in es-
iga ed whe he ope a i e ea men p o ec s om la e o a o
cu up u e and whe he i has any e ec on he de elopmen o
o a o cu muscle olume.
Pa ien s and me hods — 140 s age-II impingemen pa ien s
we e andomized o a s uc u ed exe cise g oup (n = 70) o o
an ope a i e g oup (n = 70). In he ope a i e g oup, a h oscopic
ac omioplas y was pe o med, a e which a simila s uc u ed
exe cise p og am was begun. MRI o he shoulde was done a
baseline and a 5 yea s.
Resul s — The e we e no s a is ically signi i can di e ences in
ei he he amoun o pe o a ing up u es o he sup aspina us
endon o in he changes in muscle olume a 5 yea s. The g ading
o muscle a y degene a ion showed wo se esul s in he ope a-
i e g oup, bu his di e ence was no s a is ically signi i can .
In e p e a ion — In his s udy, we ound ha a h oscopic
ac omioplas y does no ha e any long- e m bene i based on
adiological i ndings o muscle olumes. Also, he equency o
la e o a o cu up u e was simila i espec i e o whe he o
no su ge y was pe o med. Ac omioplas y is no jus i i ed as a
ea men o dynamic shoulde impingemen synd ome.
■
A h oscopic ac omioplas y is commonly used in he ea -
men o shoulde impingemen (Vi ale e al. 2010, Yu e al.
2010), e en hough i s bene i s ha e been ques ioned (B ox
e al. 1999, Haah e al. 2006, Ke ola e al. 2009, 2013). The
ope a ion does no appea o b ing any addi ional alue o he
ea men compa ed o s uc u ed exe cise ea men alone;
no is i cos -e ec i e (Ke ola e al. 2009, 2013). Ac omio-
plas y is equen ly used a e ailed non-ope a i e ea men ,
ye he e is no p oo ha hese pa ien s would bene i om he
ope a ion ei he (Ke ola e al. 2015).
Ac omial mo phology changes wi h age. Inc ease in he
numbe s o ype-III ac omion, a hooked- ype, has been
epo ed in pa ien s o e 50 yea s o age. Ye he incidence o
ype-III ac omions in symp oma ic pa ien s is lowe han in
asymp oma ic pa ien s, indica ing ha he p esence o ype-III
ac omion does no in i sel p oduce impingemen synd ome
(Wang and Shapi o 1997). The incidence o bo h asymp om-
a ic and symp oma ic cu ea s inc eases wi h age (Yamagu-
chi e al. 2001, No e-Josse and e al. 2005, Yamamo o e al.
2010). A long- e m p o ec i e e ec o a h oscopic ac omio-
plas y on o a o cu endons has been sugges ed (Nee 1972,
1983), bu his has no been e i i ed by mode n MRI s udies.
In his andomized s udy, we analyzed 140 pa ien s wi h
shoulde impingemen synd ome using MRI a baseline and
a e 5 yea s, o i nd ou whe he ope a i e ea men does
indeed p o ec om o a o cu up u e la e in li e and
whe he i has any e ec on he muscle olume.
Pa ien s and me hods
Be ween 2001 and 2004, we ec ui ed 140 pa ien s who had a
clinically p o en shoulde impingen synd ome ha had been
symp oma ic o a leas 3 mon hs. The diagnosis was based
on anamnes ic in o ma ion, ypical symp oms, and clinical
i ndings including he Nee injec ion es . MRI o he shoulde
was aken. The pa ien s we e collec ed om he Kan a-Häme
Heal h Ca e Dis ic , which had a popula ion o 165,000 a he
9632 Ke ola D.indd 3519632 Ke ola D.indd 351 6/30/2016 6:14:51 PM6/30/2016 6:14:51 PM
352 Ac a O hopaedica 2016; 87 (4): 351–355
ime o he ec ui men . Only pa ien s who had no had any
p e ious shoulde ope a ion we e included in he s udy. The
mean age o he pa ien s a baseline was 47 (23–60) yea s (88
women). The mean heigh o he pa ien s was 169 (151–193)
cm (men 178 cm, women 164 cm).
Sel - epo ed pain on a isual analog scale (VAS; 0–10) was
used as he p ima y heal h ou come measu e.
A en ollmen , 134 pa ien s we e examined wi h MRI scan-
ning. 6 pa ien s we e no examined because o claus ophobia
o obesi y, o due o ha ing me al implan s in hei bodies.
A he 5-yea con ol isi , we we e able o each 109 o he
pa ien s o clinical examina ion (52 in he exe cise g oup and
57 in he combined ea men g oup) and a con ol MRI was
done in 90 pa ien s (42 and 48, espec i ely).
The pa ien s we e andomized o 2 ea men g oups
(Figu e). In he combined ea men g oup, a h oscopic
ac omioplas y was ca ied ou wi h a subsequen supe ised
and s uc u ed exe cise egime. The same exe cise egime was
used in he o he g oup also, bu wi h no p io su gical ea -
men . Fo a ull s udy p o ocol, see Ke ola e al. (2009), which
epo s he 2-yea clinical esul s o hese pa ien s, including
he cos e ec i eness.
MRI o he shoulde was ca ied ou a baseline be o e
andomiza ion. The MRI examina ions we e pe o med in 2
adiological cen e s belonging o he hospi al dis ic (Kan a-
Häme Cen al Hospi al and Fo ssa Regional Hospi al).
A Kan a-Häme Cen al Hospi al, he shoulde s we e
scanned wi h a Philips Gy oscan In e a T10-NT 1.0 T mag-
ne ic esonance imaging sys em; a Fo ssa Regional Hospi-
al, hey we e scanned wi h a Philips Gy oscan T5-NT 0.5 T
sys em. In each imaging, a dedica ed shoulde su ace coil
was used.
Follow-up MRI scanning was done 5 yea s a e andom-
iza ion, a Kan a-Häme Cen al Hospi al wi h he 1.0 T MRI
sys em desc ibed abo e. A dedica ed shoulde su ace coil
was used. The scans we e analyzed a Kan a-Häme Cen al
Hospi al on a Fuji PACS wo k s a ion and a he Radiology
Depa men , Tampe e Uni e si y Hospi al on a Ba co MFGD
2320 wo k s a ion (wi h Impax DS3000 5.2 so wa e).
MRI examina ions we e e alua ed by 2 independen , expe-
ienced musculoskele al adiologis s. They bo h i lled ou a
s uc u ed MRI o m o each pa ien , and we e blind ega d-
ing he pa ien ’s medical his o y and ea men g oup. A sepa-
a e o m was i lled ou o he baseline and o he 5-yea
ollow-up. Each pa ien ’s esul s we e e alua ed on sepa a e
occasions o a oid in aobse e bias. The esul s ob ained by
he 2 adiologis s we e combined, and a consensus s a emen
was p epa ed in cases wi h in e obse e disag eemen . The
consensus s a emen was based on e-e alua ion o he MRI
esul s in such cases. These consensus alues we e used in
u he analyses.
The ac omial shape was e alua ed acco ding o Bigliani as
ype-I (s aigh o l a ), ype-II (cu ed), o ype-III (hooked)
(Mo ison e al. 1987) on sagi al MRI scans using a leas 2
o he mos la e al slices o he ac omion (B igh e al. 1997,
Maye hoe e e al. 2005). A his poin , o he a ia ions o he
ac omial o m we e also no ed—as well as possible hicken-
ing o he co aco-ac omial ligamen and c anializa ion o he
hume us (Saupe e al. 2006). The endons we e e alua ed o
endinosis and possible ea s. The muscle olume quan i y was
es ima ed using a me hod de eloped by Leh inen e al. (2003)
in which he muscle olume is calcula ed based on he a ea o
2 T1-weigh ed sagi al scans. The olume was also es ima ed
by he Tangen sign me hod (Zane i e al. 1998).
The a y degene a ion o he muscles was g aded acco d-
ing o he Gou allie me hod, using T1-weigh ed sagi al MRI
slices. The g ading was di ided in o 5 s eps: s age 0 co e-
sponds o a comple ely no mal muscle, wi hou any a y
s eak; in s age 1, he muscle con ains some a y s eaks; in
s age 2, he a y in i l a ion is impo an , bu he e is s ill mo e
muscle han a ; in s age 3, he e is as much a as muscle; and
in s age 4, mo e a han muscle is p esen (Gou allie e al.
1994, Fuchs e al. 1999).
S a is ics
McNema ’s es was used o compa e he shape o he ac o-
mion be o e and 5 yea s a e he in e en ion. Fishe ’s exac
es was used o compa e Gou allie s ages be ween ope a ed
None o he pa ien s
mee ing inclusion c i e ia
e used o pa icipa e
Randomisa ion
n = 140
Exe cise g oup
n = 70
67 MRIs
Ope a ed
n = 4
52 blinded isi s (ou o 70)
D op ou s:
– could no be con ac ed 7
– loss o in e es 6
– mo ed a 3
– malignancy 1
– dead 1
In en ion- o- ea analysis
a 5 yea s
52/70 = 74%
42 MRIs
Ope a ed
n = 14
Combined ea men g oup
n = 70
67 MRIs
In en ion- o- ea analysis
a 24 mon hs
68/70 = 97%
Cancelled he ope a ion
bu wan ed i la e
n = 1
57 blinded isi s (ou o 70)
D op ou s:
– could no be con ac ed 8
– loss o in e es 4
– dead 1
In en ion- o- ea analysis
a 5 yea s
57/70 = 81%
48 MRIs
Did no ecei e/cancelled
alloca ed in e en ion
n = 13
In en ion- o- ea analysis
a 24 mon hs
66/70 = 94%
The pa ien s ep esen ed in a l owcha acco ding o he ea men
g oups (in en ion- o ea ) a baseline, 2 yea s, and 5 yea s.
9632 Ke ola D.indd 3529632 Ke ola D.indd 352 6/30/2016 6:14:51 PM6/30/2016 6:14:51 PM
Ac a O hopaedica 2016; 87 (4): 351–355 353
and non-ope a ed g oups. Any p- alue < 0.05 was conside ed
o be s a is ically signi i can . S a is ical analyses we e pe -
o med using IBM SPSS S a is ics e sion 19.0.
E hics and egis a ion
The s udy was app o ed by he e hics commi ee o he hos-
pi al dis ic (E09/2001) and is egis e ed a ClinicalT ials.go
(iden i i e : NCT00349648).
Resul s
The olumes o m. sup aspina us, m. in aspina us, and m. sub-
scapula is a baseline a e p esen ed in Table 1, oge he wi h
esul s om p e iously published s udies—mainly conce ning
heal hy shoulde s. All he muscle olumes in his s udy dimin-
ished du ing ollow-up. This change was s a is ically signi i -
can in m. sup aspina us (p = 0.004) bu no in m. in aspina us
o subscapula is (p = 0.3 and p = 0.4, espec i ely).
We also analyzed he muscle olumes in di e en subg oups:
hose pa ien s who ully ollowed he andomized ea men
p o ocol, ei he in he exe cise g oup o he combined ea -
men g oup, and also hose who wan ed and had su ge y in he
exe cise g oup du ing he 5 yea s o ollow-up (18 pa ien s).
The e we e no s a is ically signi i can di e ences in changes
in muscle olume be ween he g oups. In he combined ea -
men g oup he olume o m. sup aspina us dec eased by 7%,
and in he exe cise g oup i dec eased by 4% (p = 0.6). The
changes in m. subscapula is (p = 0.5) and m. in aspina us (p
= 0.9) we e no signi i can ly di e en be ween g oups. The
muscle olume o m. sup aspina us diminished by 10% in
pa ien s wi h a pa ial ea , and 23% in hose diagnosed wi h
o al up u e.
The g ading o muscle a y degene a ion showed ha 65%
o he pa ien s who we e ope a ed had a leas some a y
s eaks, as compa ed o 54% in he non-ope a i e g oup. This
11 pe cen age poin di e ence was no s a is ically signi i -
can (p = 0.3). O e all, he e we e no signi i can di e ences
be ween he g oups ega ding a y degene a ion o any g ade
(Table 2, see Supplemen a y da a). The shape o he ac o-
mion acco ding o Bigliani a baseline was ype-I o 45% o
pa ien s, ype-II o 43%, and ype-III o 11%.
In o al, 15 pa ien s had a ull- hickness ea o he sup aspi-
na us endon a 5 yea s. 8 o hese had had ac omioplas y. O
hese pa ien s, a baseline MRI 4 had ype-I ac omion, 9 had
ype-II ac omion, and 2 had ype-III ac omion (p = 0.7).
A baseline, he p opo ion o pain- ee pa ien s (VAS 0–3)
was 11% in Bigliani I, 4% in Bigliani II, and 8% in Bigliani
III. Thus, no co ela ion was ound be ween he shape o he
ac omion and pain. Mean alues (VAS) o sel - epo ed pain
we e 6.5 o ype I, 6.8 o ype II, and 6.5 o ype III (p = 0.8).
The majo i y o he ype-II ac omions ha had ac omio-
plas y we e s ill ype-II a 5 yea s; none we e ype-I. One- hi d
o he ype-I ac omions had u ned o ype-II. A e ac omio-
plas y, 5 o 6 ac omions o ype III we e ype I–II a 5 yea s. In
he non-ope a ed g oup, he e we e no s a is ically signi i can
changes du ing he ollow-up pe iod (Table 3, see Supplemen-
a y da a)
E usion in he subac omial bu sa was epo ed as being
p esen o no . Mos o he pa ien s had suba omial bu sal e u-
sion a baseline (76%) and also a 5 yea s (80%). In hose wi h
no bu sal i i a ion he mean sel - epo ed pain alue (VAS)
was 6.8 a 5 yea s, and in hose wi h subac omial bu sal l uid
i was 6.6 (p = 0.7).
The co aco-ac omial ligamen was mo e likely o be hick-
ened a 5 yea s in pa ien s who had had ac omioplas y han in
hose who we e no ope a ed (44% s. 20%; p = 0.02).
The mean subac omial dis ance a baseline was 8.2 mm in
ope a ed pa ien s and 7.5 mm in hose who we e no ope a ed
(p = 0.03). Whe he o no his mino di e ence is o any clini-
cal impo ance is unclea .
Discussion
In he ope a ed and he non-ope a ed g oups, we ound a simi-
la equency o subsequen o a o cu endon up u es and a
simila di e ence in change in muscle olume bo h a baseline
and a 5 yea s.
A h oscopic ac omioplas y has been gi en suppo on he
assump ion ha by enhancing he mechanical si ua ion, he
sup aspina us muscle- endon uni would degene a e mo e
slowly; he decomp ession has been hough o p e en endon
up u es in he long un (Bjo nsson e al. 2010). In he p es-
en s udy, he p ocedu e did no appea o p o ec om endon
up u e, o diminish he degene a ion o he muscle mass.
Hal o he non-ope a ed pa ien s had a comple ely no mal
sup aspina us muscle wi hou any a y s eaks. The p opo -
ion was smalle in he ope a i e g oup (35%), bu his i nding
was no s a is ically signi i can .
The p opo ion o ype-III ac omion appea s o become
highe along wi h ageing. The p e alence is 16% a 30–50
yea s and 31% in indi iduals o e 50 yea s o age (Gill e
al. 2002). Any in l uence o ac omial mo phology on he o a-
o cu ea s has no been clea ly p o en. S ill, some au ho s
ha e conside ed i o be impo an while o he s ha e hough
Table 1. The olumes (cm3) o o a o cu muscles a baseline and
a 5 yea s wi h e e ence alues om he p e ious li e a u e
M. sup a- M. in a- M. sub-
spina us spina us scapula is
This s udy a baseline 49 127 120
This s udy a 5 yea s 46 114 110
Juul-K is ensen e al. (2000) 49 125 154
Leh inen e al. (2003) 36 96 99
Holzbau e al. (2007) 50 119 165
Vid e al. (2012) 40 102 103
9632 Ke ola D.indd 3539632 Ke ola D.indd 353 6/30/2016 6:14:51 PM6/30/2016 6:14:51 PM
354 Ac a O hopaedica 2016; 87 (4): 351–355
ha he changes in mo phology could be he esul o he
degene a i e o a o cu disease a he han he cause (Ozaki
e al. 1988, Nicholson e al. 1996, Wang and Shapi o 1997,
Shah e al. 2001). In ou s udy, 11% o he pa ien s (15 o
134) had ype-III ac omion. Only 2 o hose 15 pa ien s who
had de eloped a sup aspina us up u e had a ype-III ac o-
mion. Ou i ndings a e consis en wi h he esul s o Moo e
al. (2014) ega ding he lack o associa ion be ween Bigliani
ype o ac omion and cu ea s. Howe e , hey conside ed he
c i ical shoulde angle o be he mos accu a e p edic o o a
pa ien ’s indi idual isk o expe iencing o a o cu ea . Also,
Hy önen e al. (1998) ha e shown ha a o a o cu ea may
appea a e open ac omioplas y, e en hough he e was no
e idence o a cu lesion a he ime o ope a ion. In he p es-
en s udy, mo e han one- hi d o ype-I ac omions degene -
a ed in o ype-II despi e he ea men . The e-shaped o m is
no ully sus ained in ac omions o ype II–III ei he .
Shoulde impingemen synd ome in ol es a deg ee o
in l amma ion o he bu sa in he subac omial space (Bigliani
e al. 1997). This educes he olume o subac omial space.
Based on ou i ndings, his is a e y common i nding in hese
pa ien s and does no co ela e wi h he symp oms a all.
Ou s udy had some s eng hs and weaknesses. The e we e
90 con ol MRI examina ions a 5 yea s as compa ed o 134
a baseline. The adiological e alua ions o he shoulde s we e
done using MRI scans, including he Bigliani classi i ca ion.
Usually plain adiog aphs a e used, bu he MRI me hod has
been shown o be accu a e when using a combina ion o 2
MRI slices (Maye hoe e e al. 2005). Acco ding o he cu -
en li e a u e, MR a h og aphy is mo e sensi i e in de ec -
ing o a o cu ea s han MRI alone. This is especially ue
wi h pa ial- hickness ea s. We did no use a h og aphy, and
his may o some ex en ha e a ec ed he incidence o mino
cu ea s de ec ed. Howe e , he me hod was he same in bo h
s udy g oups, so he esul s in he g oups a e compa able.
In summa y, a e p e iously showing he ine i cacy o he
a h oscopic ac omioplas y in imp o ing subjec i e symp-
oms o he shoulde impingemen synd ome, we now show
ha his p ocedu e p obably has no long- e m bene i ega d-
ing he de elopmen o o a o cu endon up u es, o ega d-
ing muscle olumes. Based on he combined esul s, i appea s
ha a h oscopic ac omioplas y is no jus i i ed in he ea men
o shoulde impingemen synd ome.
Supplemen a y da a
Tables 2 and 3 a e a ailable on he Ac a O hopaedica websi e
a www.ac ao hop.o g, iden i i ca ion numbe 9632.
SKe and IA planned he s udy. SKe and JL ec ui ed he pa ien s. SKe, JL,
and IA o ganized he s udy. SKe collec ed and o ganized he da a. PE and
SKo pe o med he adiological e alua ions. SKe and HH pe o med he s a-
is ical es ing. JL and IA pe o med clinical analysis o he da a. SKe and JL
e iewed he li e a u e. SKe w o e he d a manusc ip and all he au ho s
ga e c i ical commen s o imp o emen o he a icle.
Bigliani L U, Le ine W N. Subac omial impingemen synd ome. J Bone Join
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Bjo nsson H, No lin R, Knu sson A, Adol sson L. Fewe o a o cu ea s
i een yea s a e a h oscopic subac omial decomp ession. J Shoulde
Elbow Su g 2010; 19(1): 111-5.
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Fuchs B, Weishaup D, Zane i M, Hodle J, Ge be C. Fa y degene a ion
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Gill T J, McI in E, Koche M S, Homa K, Mai S D, Hawkins R J. The ela-
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cu pa hology. J Shoulde Elbow Su g 2002; 11(4): 327-30.
Gou allie D, Pos el J M, Be nageau J, La au L, Voisin MC. Fa y muscle
degene a ion in cu up u es. P e- and pos ope a i e e alua ion by CT
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