Joint position sense is not altered during shoulder medial and lateral rotations in female assembly line workers with shoulder impingement syndrome


Haik, M.N.; Camargo, P.R.; Zanca, G.G.; Alburquerque-Sendín, F.; Salvini, T.F.; Mattiello-Rosa, S.M.

Physiotherapy: Theory and Practice 29(1): 41-50

2013


This study evaluated joint position sense (JPS) during medial and lateral rotations of the shoulder in female workers with and without shoulder impingement syndrome (SIS). Three groups were assessed. The case group consisted of 15 female assembly line workers (35.5, SD 5.8 years) with unilateral SIS. Control group 1 consisted of 15 female assembly line workers asymptomatic for SIS (34.4, SD 5.5 years) and control group 2 consisted of 15 female subjects (33.1, SD 6.2 years) asymptomatic for SIS and with no exposure to activities with the upper limbs. The JPS was evaluated bilaterally during passive (2°/sec) and active (5°/sec) repositioning tests using an isokinetic dynamometer. The target angles were 45° of lateral rotation (achieved by medially rotating the shoulder from 90° of lateral rotation) and 75° of lateral rotation (achieved by laterally rotating the shoulder from neutral rotation). There were no differences between sides for all groups (p  >  0.05). There were no differences in any of the variables between the case group and the control groups (p  >  0.05). The results of this study suggest that JPS during medial and lateral rotations of the shoulder is not altered in female assembly line workers with SIS.

Physiotherapy
Theory
and
Practice,
29(1):41-50,
2013
Copyright
©
Informa
Healthcare
USA,
Inc.
ISSN:
0959-3985
print/1532-5040
online
001:
10.3109/09593985.2012.676722
informa
healthcare
RESEARCH
REPORT
Joint
position
sense
is
not
altered
during
shoulder
medial
and
lateral
rotations
in
female
assembly
line
workers
with
shoulder
impingement
syndrome
Melina
N.
Haik
PT
1
,
Paula
R.
Camargo
PT,
MS,
PhD',
Gisele
G.
Zanca
PT,
MS
1
,
Francisco
Alburquerque-Sendin'
PT,
MS,
PhD
2
,
Tania
F.
Salvini
PT,
MS,
PhD',
and
Stela
M.
Mattiello-Rosa
PT,
MS,
PhD
1
'Department
of
Physical
Therapy,
Federal
University
of
Sao
Carlos,
Sao
Carlos,
SP,
Brasil
2
Department
of
Physical
Therapy,
University
of
Salamanca, Salamanca,
Spain
ABSTRACT
This
study
evaluated
joint
position
sense
(JPS)
during
medial
and
lateral
rotations
of
the
shoulder
in
female
workers
with
and
without
shoulder
impingement
syndrome
(SIS).
Three
groups
were
assessed.
The
case
group
consisted
of
15
female
assembly
line
workers
(35.5,
SD
5.8
years)
with
unilateral
SIS.
Control
group
1
con-
sisted
of
15
female
assembly
line
workers
asymptomatic
for
SIS
(34.4,
SD
5.5
years)
and
control
group
2
con-
sisted
of
15
female
subjects
(33.1,
SD
6.2
years)
asymptomatic
for
SIS
and
with
no
exposure
to
activities
with
the
upper
limbs.
The
JPS
was
evaluated
bilaterally
during
passive
(2°/sec)
and
active
(5°/sec)
repositioning
tests
using
an
isokinetic
dynamometer.
The
target
angles
were
45°
of
lateral
rotation
(achieved
by
medially
rotating
the
shoulder
from
90°
of
lateral
rotation)
and
75°
of
lateral
rotation
(achieved
by
laterally
rotating
the
shoulder
from
neutral
rotation).
There
were
no
differences
between
sides
for
all
groups
(
p
>
0.05).
There
were
no
differ-
ences
in
any
of
the
variables
between
the
case
group
and
the
control
groups
(
p
>
0.05).
The
results
of
this
study
suggest
that
JPS
during
medial
and
lateral
rotations
of
the
shoulder
is
not
altered
in
female
assembly
line
workers
with
SIS.
INTRODUCTION
Shoulder
impingement
syndrome
(SIS)
has
been
described
as
a
mechanical
compression
of
the
rotator
cuff
tendons
and
subacromial
bursa
under
the
coracoacromial
arch
during
arm
elevation
(Neer,
1972).
Overhead
activities
involving
repetitive
arm
movements
in
work
and
sports
have
been
identified
as
risk
factors
for
developing
SIS
(Cools,
Cambier,
and
Witvrouw,
2008;
Frost
and
Andersen,
1999).
Integrity
of
the
sensory-motor
system
is
extremely
important
for
functional
joint
stability
of
the
shoulder
(Niessen
et
al,
2008;
Riemann
and
Lephart,
2002a,
2002b).
Proprioception
is
an
important
component
of
this
complex
system
and
is
divided
into
three
Accepted
for
publication
9
March
2012
Address
correspondence
to
Stela
M
Mattiello
Rosa,
PhD,
PT,
Depart-
ment
of
Physical
Therapy,
Federal
University
of
Sao
Carlos,
Rodovia
Washington
Luis,
km
235
CEP:
13565-905,
Sao
Carlos,
SP,
Brasil.
E-mail:
stela@ufscar.br
submodalities:
1)
joint
position
sense
(JPS);
2)
kinesthesia;
and
3)
sense
of
force
(Lephart
and
Fu,
2000;
Riemann
and
Lephart,
2002a,
2002b).
Some
studies
have
evaluated
proprioception
(Machner
et
al,
2003)
and
sensory-motor
control
(Bandholm
et
al,
2006;
Camargo
et
al,
2009;
Zanca
et
al,
2010)
of
the
shoulder
in
subjects
with
SIS.
Machner
et
al
(2003)
assessed
subjects
with
indication
for
subacro-
mial
decompression
and
found
deficits
in
kinesthetic
sense
during
shoulder
abduction
in
the
involved
side
when
compared
to
the
contralateral
side.
Although
force
steadiness
was
not
found
to
be
impaired
during
isometric
abduction
in
subjects
with
unilateral
SIS
(Bandholm
et
al,
2006;
Camargo
et
al,
2009),
deficits
were
demonstrated
during
isokinetic
concentric
abduction
(Bandholm
et
al,
2006).
Steadiness
was
also
evaluated
during
isometric
medial
and
lateral
rotations
of
the
shoulder
in
female
workers
with
SIS
compared
to
healthy
workers
(Zanca
et
al,
2010).
Alterations
in
steadiness
were
not
observed
in
these
subjects
and
the
authors
suggested
that
maintenance
41
42
Haik
et
al.
of
regular
work
activities
may
play
an
important
role
in
preserving
the
steadiness
in
this
population.
JPS
has
not
yet
been
used
to
assess
proprioception
in
subjects
with
SIS.
This
kind
of
evaluation
has
been
widely
used
to
evaluate
proprioception
in
several
shoulder
conditions
such
as
after
muscle
fatigue
(Car-
penter,
Blazier,
and
Pellizzon,
1998;
Lee
et
al,
2003;
Voight
et
al,
1996;
Winter,
Allen,
and
Proske,
2005);
in
overhead
sports
(Allegrucci
et
al,
1995;
Dover
et
al,
2003;
Safran
et
al,
2001);
in
shoulder
instability
(Barden
et
al,
2004;
Lephart,
Myers,
Bradley,
and
Fu,
2002;
Potzl
et
al,
2004;
Warner,
Lephart,
and
Fu,
1996);
after
surgical
repair
for
shoulder
instability
(Aydin
et
al,
2001;
Potzl
et
al,
2004);
after
cryotherapy
(Dover
and
Powers,
2004;
Wassinger
et
al,
2007);
and
after
plyometric
training
(Swanik
et
al,
2002).
It
has
been
well
established
that
muscle
spindles
(Gandevia,
Hall,
McCloskey,
and
Potter,
1983;
Proske,
2006;
Winter,
Allen,
and
Proske,
2005)
and
joint
mechanoreceptors
(Gandevia,
Hall,
McCloskey,
and
Potter,
1983;
Swanik
et
al,
2002;
Warner,
Lephart,
and
Fu,
1996)
play
an
important
role
in
JPS.
JPS
is
commonly
evaluated
by
active
and
passive
repositioning
tests
(Barden
et
al,
2004;
Car-
penter,
Blasier,
and
Pellizzon,
1998;
Dover
and
Powers,
2003;
Janwantanakul,
Magarey,
Jones,
and
Dansie,
2001;
Lee
et
al,
2003;
Suprak,
2011;
Suprak,
Osternig,
van
Donkelaar,
and
Karduna,
2006, 2007;
Swanik
et
al,
2002;
Voight
et
al,
1996).
Some
studies
have
shown
better
JPS
in
the
presence
of
muscular
contraction
(Proske,
2006;
Suprak,
Oster-
nig,
van
Donkelaar,
and
Karduna,
2006,
2007;
Winter,
Allen,
and
Proske,
2005),
while
others
have
demonstrated
more
position
matching
errors
with
higher
intensity
contraction
(Smith
et
al,
2009;
Walsh,
Smith,
Gandevia,
and
Taylor,
2009).
It
is
well
established
that
subjects
with
SIS
present
alterations
in
muscle
activation
(Ludewig
and
Cook,
2000;
Phadke,
Camargo,
and
Ludewig,
2009).
However,
it
is
not
known
if
these
alterations
are
due
to
possible
deficits
in
afferent
pathways
which
are
related
to
muscle
spindles
and
articular
mechanore-
ceptors
or
if
these
alterations
are
due
to
efferent
motor
command.
If
this
is
a
possibility,
then
to
assess
JPS
in
subjects
with
SIS
could
help
the
understanding
of
the
pathology
and
improve
guidelines
for
clinicians
to
develop
individualized
rehabilitation
programs,
including
restoration
of
proprioception
and
joint
neuromuscular
stabilization
mechanisms.
Considering
that
the
rotator
cuff
muscles,
mainly
the
lateral
rotators,
are
dysfunctional
in
subjects
with
SIS
(Phadke,
Camargo,
and
Ludewig,
2009),
and
given
the
lack
of
studies
about
JPS
in
subjects
with
SIS,
the
purpose
of
this
study
was
to
evaluate
JPS
during
medial
and
lateral
shoulder
rotations
in
indi-
viduals
with
SIS.
Since
assembly
line
workers
consist
of
a
population
at
risk
for
developing
shoulder
dis-
orders
(Camargo
et
al,
2007;
Leclerc
et
al,
2004),
the
groups
assessed
in
this
study
consisted
of
assembly
line
workers
with
SIS,
assembly
line
workers
asympto-
matic
for
SIS,
and
asymptomatic
subjects
with
no
exposure
to
activities
of
the
upper
limbs.
The
presence
of
the
asymptomatic
groups
with
and
without
exposure
activities
of
the
upper
limbs
provide
insight
into
whether
a
possible
decrease
in
JPS
in
the
sympto-
matic
group
is
due
to
work
adaptation
or
due
to
SIS.
The
hypothesis
of
this
study
was
that
workers
with
SIS
would
present
alterations
in
shoulder
JPS,
especially
during
active
lateral
rotation
(ALR)
when
compared
to
asymptomatic
subjects.
METHODS
Subjects
A
total
of
135
female
assembly
line
workers
from
the
same
sector
in
a
school
supply
industry
were
initially
recruited
and
evaluated.
These
workers
have
regular
exposure
to
repetitive
overhead
working,
including
repetitive
lifting
to
shoulder
height
and
above.
Of
the
135
workers
recruited,
15
were
diagnosed
with
SIS,
and
thus
comprised
the
case
group.
Two
control
groups
were
matched
to
the
case
group
with
respect
to
age,
weight,
and
height:
1)
15
female
assembly
line
workers
asymptomatic
for
SIS
(control
group
1);
and
2)
15
female
subjects
asymptomatic
for
SIS
and
with
no
exposure
to
activities
with
the
upper
limbs
(control
group
2).
As
such,
45
female
subjects
were
evaluated
in
this
study
(Table
1).
Female
workers
were
chosen
because
they
are
more
likely
to
report
physical
disability
and
pain
than
male
workers
(Camargo
et
al,
2007).
SIS
was
first
diagnosed
by
a
physical
therapist
and
later
confirmed
by
an
orthopedic
physician.
The
clini-
cal
diagnosis
of
SIS
was
made
following
the
clinical
criteria
of
pain
reproduction
on
at
least
three
of the
tests:
1)
Neer
(Neer,
1972);
2)
Hawkins
(Hawkins
and
Kennedy,
1980);
3)
Jobe
(Jobe
and
Moynes,
1982);
4)
Speed
(Calis
et
al,
2000);
and
5)
Gerber
(Gerber
and
Krushell,
1991).
Ultrasonography
for
both
involved
and
uninvolved
shoulders
was
made
to
determine
cuff
tears
by
an
experienced
musculoskele-
tal
ultrasonography
radiologist.
The
dominant
side
was
the
involved
side
for
six
of
the
subjects
and
the
non-dominant
side
was
the
involved
side
for
the
other
nine.
The
asymptomatic
subjects
were
negative
on
all
of
the
above
tests.
Copyright
©
Informa
Healthcare
USA,
Inc.
Physiotherapy
Theory
and
Practice
43
TABLE
1
Characteristics
of
the
female
subjects.
Control
Control
Case
group group
1
group
2
(n
=
15)
(n
=
15)
(n
=
15)
Age
(years)
35.5,
SD
34.4,
SD
5.5
33.1,
SD
6.2
5.8
Weight
(kg)
61.8,
SD
66.9,
SD
60.4,
SD
7.9
10.1
13.2
Height
(cm)
162.83,
SD
165.29,
SD
160.71,
SD
4.22
0.02
7.43
Duration
of
41.2,
SD
symptoms
34.9
(months)
Time
of
work
in
12.23,
SD
14.60,
SD
the
industry
5.43
6.36
(years)
Results
are
mean
SD.
Case
group,
female
workers
with
SIS.
Control
group
1,
female
workers
asymptomatic
for
SIS.
Control group
2,
non-worker
females
asymptomatic
for
SIS.
Exclusion
criteria
for
the
three
groups
included
subjects
who
were:
pregnant;
had
histories
of
partial
or
full
torn
tendons;
ligamentous
laxity
based
on
posi-
tive
Sulcus
test
(Neer
and
Foster,
1980)
and
Appre-
hension
test
(Rowe
and
Zarins,
1981);
previous
shoulder
or
neck
surgery;
systemic
illnesses;
corticos-
teroid
injection
3
months
prior
to
evaluation;
and
physical
therapy
6
months
prior
to
evaluation.
All
subjects
gave
their
written
informed
consent
to
participate
in
this
study,
which
was
approved
by
the
Ethical
Committee
of
the
University
and
conducted
according
to
the
Helsinki
Statement.
JPS
evaluation
Passive
and
active
JPS
were
evaluated,
bilaterally,
during
medial
and
lateral
rotations
of
the
shoulder
using
an
isokinetic
dynamometer
(Biodex
Multi
Joint
System
3,
Biodex
Medical
System
Inc.,
New
York,
USA).
Isokinetic
dynamometers
have
been
widely
used
to
evaluate
JPS
of
the
shoulder
(Dover
and
Powers,
2003;
Janwantanakul,
Magarey,
Jones,
and
Dansie,
2001;
Lee
et
al,
2003;
Swanik
et
al,
2002;
Voight
et
al,
1996).
Reliability
coefficients
ranging
from
0.95
to
0.99
have
been
reported
for
JPS
(Allegrucci
et
al,
1995;
Lephart
and
Fu,
2000;
Voight
et
al,
1996).
The
subjects
were
assessed
in
the
seated
position,
and
stabilization
of
the
trunk
was
provided
by
diagonal
and
pelvic
straps.
The
patients
were
blindfolded
and
had
headsets
placed
over
their
ears
to
avoid
visual
and
auditory
cues.
The
evaluation
sequence
was
randomly
chosen
as
follows:
shoulder
(left
or
right);
movement
(medial
or
lateral
rotation);
and
reposition-
ing
type
(passive
or
active).
The
contralateral
shoulder
followed
the
same
order
of
evaluation.
For
both
repositioning
tests,
the
arm
of
the
subjects
was
supported
by
a
limb-support
pad
of
the
dynam-
ometer
and
positioned
at
90°
of
shoulder
elevation
in
the
scapular
plane
with
the
elbow
in
90°
flexion
(Lee
et
al,
2003).
The
scapular
plane
was
chosen
because
it
provides
better
congruency
between
the
articular
surfaces
of
the
glenohumeral
joint
and
is
an
optimum
position
to
assess
the
action
of
the
rotator
cuff
muscles
(Cools,
Witvrouw,
Mahieu,
and
Dan-
neels,
2005;
Dupuis,
Tourny-Chollet,
Delaruea,
and
Beret-Blanquarta,
2004).
The
olecranon
was
aligned
over
the
rotational
machine
axis.
The
repositioning
was
performed
passively
and
actively
during
medial
and
lateral
rotations
of
the
shoulder
within
a
limited
lateral
rotation
range.
For
the
medial
rotation
test,
the
start
position
was
90°
of
lateral
rotation
(Carpen-
ter,
Blasier,
and
Pellizzon,
1998;
Lee
et
al,
2003)
(Figure
1(a))
and
the
target
position
was
45°
of
lateral
rotation
(Lee
et
al,
2003)
(Figure
1(b)).
For
(b)
FIGURE
1
Start
position
(a)
and
target
angle
(b)
for
medial
rotation
repositioning
test.
Physiotherapy
Theory
and
Practice
44
Haik
et
al.
'En
(b)
FIGURE
2
Start
position
(a)
and
target
angle
(b)
for
lateral
rotation
repositioning
test.
the
lateral
rotation
test,
the
start
position
was
at
neutral
rotation
(Lee
et
al,
2003;
Voight
et
al,
1996)
(Figure
2(a))
and
the
target
position
was
75°
of
lateral
rotation
(Lee
et
al,
2003;
Voight
et
al,
1996)
(Figure
2(b)).
These
two
target
angles
of
shoulder
lateral
rotation
were
chosen
in an
attempt
to
represent
the
functional
range
of
movement
during
the
working
activities.
Before
both
passive
and
active
tests,
the
shoulder
was
passively
moved
to
the
target
angle
and
held
in
this
angle
for
10
sec.
The
target
angles
were
presented
at
the
same
test
speeds;
2°/sec
and
5°/sec
for
passive
and
active
repositioning
tests,
respectively.
The
subject
was
asked
to
concentrate
on
the
presented
target
angle
and,
then
the
equipment
replaced
the
arm
to
the
start
position.
For
the
passive
repositioning
(passive
medial
rotation;
PMR
and
passive
lateral
rotation;
PLR),
the
shoulder
was
moved
to
each
rotation
at
2°/sec
and
the
subject
was
instructed
to
press
the
on/off
switch
to
stop
the
movement
when
she
thought
the
shoulder
was
at
the
target
angle.
For
the
active
repositioning
(active
medial
rotation;
AMR
and
ALR),
the
subject
moved
the
arm into
each
rotation
at
5°/sec
and
stopped
the
movement
using
the
on/off
switch
as
described
earlier.
Three
trials
were
performed
for
each
target
angle,
in
each
type
of
repositioning,
with
an
interval
of
1
minute
between
the
trials.
The
absolute
error
was
calculated
for
each
repetition
indicating
the
absolute
difference
in
degrees
between
the
target
and
matching
positions
(Baker
et
al,
2002).
The
results
were
then
analyzed
using
the
mean
of
the
absolute
error
of
the
three
rep-
etitions
for
each
movement.
Data
analysis
Statistical
analysis
was
conducted
with
the
SPSS
16.0
package
(SPSS,
Chicago,
IL,
USA).
The
absolute
error
was
used
for
statistical
analysis.
Mean,
standard
deviation
(SD),
or
95%
confidence
intervals
of
the
values
are
presented.
The
Kolmogorov—Smirnov
test
was
used
to
evaluate
the
distribution
of
data.
Each
mode
(passive
and
active)
and
rotation
(medial
and
lateral)
was
compared
separately.
Dependent
t-tests
were
used
to
compare
involved
and
uninvolved
sides
of
the
case
group,
and
dominant
and
non-dominant
sides
of
the
control
groups
1
and
2.
As
differences
were
not
found,
both
sides
of
each
group
were
grouped
to
identify
intergroup
differences,
as
pre-
viously
suggested
by
Venturini,
Oliveira,
and
Mattiel-
lo-Rosa
(2002).
Then,
a
one-factor
(group)
ANOVA
was
used
to
identify
intergroup
differences
of
the
out-
comes.
The
Tukey
test
was
used
for
post
hoc
analysis
when
necessary.
The
level
of
significance
was
set
at
0.05
for
all
statistical
analyses.
RESULTS
The
quantitative
variables
were
normally
distributed
(Kolmogorov—Smirnov,
p
>
0.05).
No
statistically
significant
differences
were
found
for
the
between-
side
comparison
of
all
variables
in
each
group
(Figure
3).
Accordingly,
most
of
the
variables
showed
a
difference
between
means
(DBM)
of
less
than
(Table
2).
Also,
as
no
statistically
significant
differences
were
found
between
sides,
side
was
not
considered
to
have
influence
on
shoulder
JPS.
The
case
group
presented
no
differences
(p
>
0.05)
in
JPS
for
PMR,
AMR,
PLR,
and
ALR
when
compared
to
the
control
groups
(Table
3).
However,
the
control
group
of
female
workers
(control
group
1)
demonstrated
impaired
JPS
when
compared
to
the
control
group
of
female
subjects
(control
group
2)
during
AMR
(Table
3).
In
fact,
this
behavior
was
also
identified
in
the
PMR,
although
without
statistical
significance.
Copyright
©
Informa
Healthcare
USA,
Inc.
(a)
20-
15-
c
rn
th
-
10-
o
3.;
0
0
a
0
co
.
5-
0-
(C)
20
O
w
C)
C
0
0
O
0.
0
(b)
20-
8
15-
c
'E
10-
o-
,a2
.
7)
0
0
u
)
5-
0
0-
(d)
20
Active
medial
rotation
(AMR)
O
Lb
if
15
ir
CI)
t..
)
0
0
10
%OM<
l'ORri
0
0
5-
0.
u)
0-
MOM
Passive
medial
rotation
(PMR)
I
(
1
1,
15-
Physiotherapy
Theory
and
Practice
45
QM
Uninvolved
side
-
case
group
EZ:1
Involved
side
-
case
group
i=
Dominant
side
-
control
group
1
Nondominant
side
-
control
group
1
CI
Dominant
side
-
control
group
2
Nondominant
side
-
control
group
2
Passive
lateral
rotation
(PLR)
Active
lateral
rotation
(ALR)
FIGURE
3
Absolute
repositioning
errors
in
both
shoulders
for
PMR,
AMR,
PLR,
and
ALR.
Case
group,
female
workers
with
SIS;
Control group
1,
female
workers
asymptomatic
for
SIS;
Control
group
2,
non-worker
females
asymptomatic
for
SIS.
TABLE
2
DBMs,
in
degrees,
from
both
sides
of
the
case
and
control
groups.
Case
group
(n
=
15)
DBMs
t-Test
(p
value)
PMR
involved/uninvolved
side
0.48
±
2.02
(-3.87,
4.83)
0.237
(0.82)
AMR
involved/uninvolved
side
0.35
±
2.22
(-4.42,
5.11)
0.156
(0.88)
PLR
involved/uninvolved
side
0.22
±
1.94
(-3.96,
4.4)
0.113
(0.91)
ALR
involved/uninvolved
side
0.75
±
2.94
(-5.57,
7.07)
0.253
(0.8)
Control
group
1
(n
=
15)
PMR
dominant/non-dominant
side
-2.33
±
2.14
(-6.94,
2.28)
-1.09
(0.3)
AMR
dominant/non-dominant
side
3.49
±
2.00
(-0.82,
7.80)
1.73
(0.10)
PLR
dominant/non-dominant
side
0.92
±
1.82
(-4.84,
3.00)
-0.5
(0.62)
ALR
dominant/non-dominant
side
2.93
±
3.69
(-4.98,
10.85)
0.8
(0.44)
Control
group
2
(n
=
15)
PMR
dominant/non-dominant
side
1.04
±
1.21
(-1.57,
3.65)
0.86
(0.41)
AMR
dominant/non-dominant
side
1.20
±
1.09
(-1.15,
3.55)
1.1
(0.29)
PLR
dominant/non-dominant
side
0.56
±
2.05
(-3.85,
4.96)
0.27
(0.79)
ALR
dominant/non-dominant
side
1.56
±
2.16
(-3.1,
6.21)
0.72
(0.49)
Comparative
tests
are
also
presented.
Mean
±
standard
error
(95%
coefficient
interval).
DBM,
difference
between
means;
PMR,
passive
medial
rotation;
AMR,
active
medial
rotation;
PLR,
passive
lateral
rotation;
ALR,
active
lateral
rotation.
Case
group,
female
workers
with
SIS.
Control
group
1,
female
workers
asymptomatic
for
SIS.
Control
group
2,
non-worker
females
asymptomatic
for
SIS.
Physiotherapy
Theory
and
Practice
,
a
c
t
ive
la
te
ra
l
ro
ta
t
ion.
6
O
Con
tro
l 1
vs.
Con
tro
l
2
0'
N
4)
O
co
7,1
cc)
X000
to
0
aN
e
,
r•-•
cc
.
t-
Ir?
00
I
N
v
v
4
in
oo
.zr
A
i
to
1
/4
0
1 /4
R
If)
N
V)
In
N
00
to
1 /4
°
iR
Cl
in
co
-
t
e
p,
„_..7
at
,
-4
N.
,
4
,
_
c
o,
N
K1
W
`
,
g
tri
4
r
S
to
2
(1
ai
4 4
to
N
to
a,
Cl
In
.3.
O\
oo
O
In
trl
If)
00
In
0
0
6
o
,-/
•-.1
(NI
Cl
in
00
01
CP
,
in
C
1 /4
1
4
4
cn
0
1 /4
00
V,
criooaimin.zroo
oe.
cri
1-:
oe, tr-;
4
c;
.-44
-4 -4
0 0 0 0
0 0 0 0
en en en en en en en
cr,
II
II
a
II
II
II II
5
.
II
II
tflocfizgcnvi
-
nv
,"
N
II
(\i
11
ti
(..q
11
c
s
1
0,00f:1,000,00g:1,00
0
LA
to
geo
g
tb
g
to
to
4
O
.
O
bb
00°&100`g00`g00
o
o
o
0
CCI
0 0
o
o
C.)
U
U
U
U
C.)
U
U
(.)
C..) C.)
U
in
O
0
v
0
..,
o
,,,
g
-
o
'
-
'
0
74
s-
,
F.
CO
u
>
.?..
O
`43
a
g
co
(-)
P.4
,...
.
0
V
0
4
i
4
0
r
,.;
1.
O
V.1
1:4'
c,..
9
V)
u
".
-a
,,
.
0
-ei:ig
,4.9 cd
d
t)
6)
P
U
WI
P
-•
.g
4)
C
a
3
4-.
.0
2
P-•
O
es Cii gs'
73
"
vi
f
>
tIO
1-,
c„
CO
n
crs C
O
.
4
aq
4
.
Y
A
<4...
1...
in
0 0
,
-,
••.,
.z:
iu
p•
4
4)
0
O
1.4
0
7d
.
ti
'8
au 4.2.
C
g
g
'-'
c•i*
w
o
.
ri,
,?4
,
1)
4-4
Re
6:14
113
6
0o
0
cc
c''
f'
s
0
ti
4
+1
0
4
-
ci
15
1:1
,.
0
0
Cr
(.7
0
0
as
o
o
+1 +1
+1
+1
+1 +1
+1 +1
+1
+1
+1
+1
Mea
n
e
rro
r
(
°)
a,
In
V)
Rep
os
it
ion
ing
tes
t
TABLE
3
Resu
lts
o
f
t
he
jo
in
t
p
os
it
ion
sense,
in
deg
rees,
for
eac
h
g
ro
up
(p
os
t
hoc
ana
ly
s
is:
Tu
key
tes
t).
46
Haik
et
al.
DISCUSSION
The
purpose
of
this
study
was
to
evaluate
JPS
during
medial
and
lateral
shoulder
rotations
within
a
limited
lateral
rotation
range
of
motion
in
individuals
with
SIS.
This
investigation
showed
that
JPS
is
not
altered
during
medial
and
lateral
rotations
of
the
shoulder
in
female
assembly
line
workers
with
SIS.
However,
it
was
possible
to
note
alterations
in
JPS
during
AMR
in
asymptomatic
female
assembly
line
workers
exposed
to
overhead
activities.
These
results
are
not
supportive
of
the
hypothesis
that
workers
with
SIS
would
present
alterations
in
JPS,
especially
during
ALR
of
the
shoulder.
It
is
difficult
to
make
direct
comparison
of
the
present
findings
with
other
studies
as
this
is
the
first
one
to
report
JPS
in
subjects
with
SIS.
Few
studies
(Bandholm
et
al,
2006;
Camargo
et
al,
2009;
Zanca
et
al,
2010)
have
used
steadiness
to
evaluate
the
sensory-motor
control
in
subjects
with
SIS,
but
altera-
tions
were
not
found
when
the
subjects
were
com-
pared
to
a
control
group.
The
previous
investigations
suggested
that
sensory-motor
control
is
not
affected
by
chronic
shoulder
pain
in
subjects
with
SIS
who
are
engaged
in
activities
of
muscle
training
for
the
upper
limbs.
It
is
possible
that
inhibitory
effects
of
shoulder
pain
could
have
been
counterbalanced
by
the
excitatory
effects
of
upper-body
physical
activity
(Bandholm
et
al,
2006;
Camargo
et
al,
2009).
In
our
study,
despite
of
pain,
both
worker
groups
usually
spend
about
half
of
their
working
hours
with
the
arms
in
elevated
positions
performing
the
usual
tasks
of
their
jobs.
The
maintenance
of
the
upper-body
work
activities
in
these
subjects
might
have
prevented
shoulder
proprioceptive
deficits.
Kinesthesia
was
also
used
to
evaluate
propriocep-
tion
in
subjects
with
SIS
who
were
treated
with
arthro-
scopic
subacromial
decompression
(Machner
et
al,
2003).
The
kinesthetic
sense
was
assessed
during
shoulder
abduction
at
1.3°/sec.
The
movement
detec-
tion
threshold
was
increased
before
the
surgery
in
these
subjects,
but
it
was
completely
recovered
after
arthroscopic
subacromial
decompression.
The
authors
related
the
proprioceptive
deficits
to
the
de-
creased
afferent
impulses
from
the
mechanoreceptors
of
the
bursa
and
coracoacromial
ligament
(Machner
et
al,
2003).
As
deficits
were
not
found
in
this
study,
we
should
highlight
some
differences
between
the
pre-
vious
study
and
the
present
one
that
may
not
have
con-
tributed
to
finding
differences
between
our
case
and
control
groups.
None
of
our
subjects
had
indication
for
subacromial
decompression,
which
may
suggest
that
proprioceptive
deficits
are
related
to
later
stages
of
the
SIS.
The
different
methods
and
movements
tested
may
also
have
influenced
the
results.
As
Copyright
©
Informa
Healthcare
USA,
Inc.
Physiotherapy
Theory
and
Practice
47
impingement
is
reported
to
occur
mainly
during
shoulder
abduction
(Michener,
McClure,
and
Karduna,
2003),
perhaps
proprioceptive
deficits
are
more
evident
during
this
movement.
However,
it
is
important
to
state
that
shoulder
rotations
at
90°
of
ab-
duction
might
contribute
to
internal
impingement
(Sorensen
and
Jorgensen,
2000).
The
lack
of
differences
between
dominant
and
non-
dominant
sides
in
the
control
groups
is
in
accordance
with
other
studies
that
also
demonstrated
no
domi-
nance
influence
in
proprioception
in
healthy
subjects
(Aydin
et
al,
2001;
Carpenter,
Blasier,
and
Pellizzon,
1998;
Voight
et
al,
1996).
Moreover,
no
differences
were
found
between
involved
and
uninvolved
sides
of
the
workers
with
SIS.
Other
investigations
have
also
shown
no
side-to-side
differences
in
subjects
with
SIS
with
a
more
symmetrical
use
of
the
arms
(Camargo
et
al,
2008,
2009;
Mattiello-Rosa
et
al,
2008)
as
demonstrated
by
our
workers.
As
the
case
group
presents
chronicity
of
symptoms
(41.2
±
34.9
months),
we
can
hypothesize
that
a
compensatory
mechanism
might
have
occurred
leading
to
the
similarity
with
the
control
groups.
Sur-
prisingly,
the
only
statistical
difference
found
in
this
study
was
between
the
control
groups
during
the
AMR
repositioning
test,
in
which
the
control
group
of
asymptomatic
workers
(control
group
1)
demon-
strated
higher
absolute
errors.
As
the
female
workers
in
the
case
group
and
control
group
1
were
exposed
to
the
same
occupational
risk
factor
for
developing
SIS,
one
explanation
for
this
difference
may
be
that
individuals
in
control
group
1
are
in
the
early
stages
of
impairment
although
still
asymptomatic.
If
the
sub-
jects
in
control
group
1
become
symptomatic
and
their
symptoms
reach
chronicity
later
in
life,
they
may
also
develop
a
compensatory
proprioception
mechanism.
Although
it
was
not
the
purpose
of
this
study,
it
is
interesting
to
note
that
active
repositioning
was
gener-
ally
observed
to
be
less
accurate
compared
to
passive
repositioning.
This
trend
is
present
for
both
shoulder
rotations
in
all
groups
evaluated
(Table
2).
The
passive
repositioning
test
has
been
more
commonly
used
to
evaluate
proprioception
Ganwantanakul,
Magarey,
Jones,
and
Dansie,
2001;
Niessen
et
al,
2008;
Warner,
Lephart,
and
Fu,
1996;
Wassinger
et
al,
2007),
but
active
repositioning
should
also
be
considered
as
it
better
represents
joint
function
(Aydin
et
al,
2001;
Barden
et
al,
2004;
Dover
and
Powers,
2003,
2004;
Potzl
et
al,
2004;
Swanik
et
al,
2002;
Wassinger
et
al,
2007).
The
role
of
muscle
receptors
as
position
sensors
was
analyzed
in
a
review
study
(Proske,
2006).
It
is
known
that
muscle
spindles
are
able
to
generate
position
sense
signals
in
response
to
muscle
length
changes
(Gandevia,
Hall,
McCloskey,
and
Potter,
1983;
Goodwin,
McCloskey,
and
Matthews,
1972)
as
well
as
from
fusi-
motor
activity
(Proske,
2006),
which
occurs
during
a
vo-
luntary
contraction.
Proske
(2006)
also
considers
that
both
types
of
spindle
information
(passive
and
active)
would
be
incorporated
with
a
centrally
generated
effort
signal
to
provide
proper
JPS
during
active
positioning.
It
should
also
be
stated
that
although
muscle
spindle
sensitivity
is
dependent
on
intrafusal
muscle
contraction,
this
dependency
appears
to
be
progressively
less
as
the
level
of
muscle
activity
increases
(Suprak,
2011;
Winter,
Allen,
and
Proske,
2005).
This
fact
may
have
contributed
to
the
less
accurate
active
JPS
in
this
study
or
we
can
suggest
that
fusimotor
system
may
be
impaired
in
these
female
workers
resulting
in
worst
JPS
in
the
presence
of
muscle
contraction.
In
contrast,
as
fusimotor
system
activity
during
vo-
luntary
contractions
has
also
been
attributed
to
better
JPS
in
active
tasks
(Lunn
et
al,
2000;
Winter,
Allen,
and
Proske,
2005),
more
studies
are
still
necessary
to
conclude
on
the
real
effects
of
this
system
in
JPS.
In
addition,
Barden
et
al
(2004)
have
suggested
that
dynamic
proprioceptive
feedback
generated
by
motion
is
used
to
refine
the
movement
according
to
limb
dynamics
information
not
available
to
the
central
nervous
system
before
movement
initiation.
The
rotator
cuff
muscles
play
an
important
role
for
shoulder
stability
and
function
(Lephart
and
Fu,
2000;
Riemann
and
Lephart,
2002a,
2002b)
and
al-
terations
in
activation
of
these
muscles
have
been
associated
with
SIS
(Phadke,
Camargo,
and
Ludewig,
2009).
The
lateral
rotators
are
weaker
in
subjects
with
SIS
compared
to
the
same
muscles
in
healthy
subjects
(Ellenbecker
and
Davies,
2000;
Warner
et
al,
1990)
and
this
weakness
may
be
due
to
deficits
in
afferent
pathways.
In
this
study,
the
higher
absolute
errors
found
in
control
group
1
during
AMR
may
suggest
some
proprioception
deficit
resulting
from
poor
lateral
rotators
afferent
information
from
the
lengthening
of
these
muscles
during
medial
rotation
movement.
It
is
also
interesting
to
note
that
full
proprioceptive
acuity
depends
upon
the
availability
of
receptors
in
muscles,
skin,
and/or
joints
(Gandevia,
Hall,
McClos-
key,
and
Potter,
1983).
Despite
the
importance
of
muscle
spindles
in
position
sense,
other
mechanore-
ceptors
(i.e.,
Pacinian
corpuscles,
Ruffini
receptors,
Golgi
endings,
and
free
nerve
ending)
also
contribute
to
proprioceptive
qualities
through
electrical
inputs
to
the
central
nervous
system
(Tibone,
Fechter,
and
Kao,
1997;
Vangsness
and
Ennis,
1992).
This
is
sup-
ported
by
studies
that
showed
decreased
proprioception
in
shoulder
instability
and
SIS,
for
example,
and
found
that
deficits
were
restored
after
surgical
repair
(Aydin
et
al,
2001;
Machner
et
al,
2003;
Myers,
Wassinger,
and
Lephart,
2006;
Potzl
et
al,
2004).
This
Physiotherapy
Theory
and
Practice
48
Haik
et
al.
improvement
in
proprioception
was
attributed
to
res-
toration
of
the
afferent
impulse
from
mechanoreceptors
of
the
restraints
and
bursa
(Aydin
et
al,
2001;
Machner
et
al,
2003;
Myers,
Wassinger,
and
Lephart,
2006;
Potzl
et
al,
2004).
As
such,
considering
that
no
differ-
ences
were
found
between
the
case
group
and
control
groups
and
as
the
subjects
of
this
study
had
no
indi-
cation
for
subacromial
decompression;
another
poss-
ible
reason
for
the
absence
of
proprioceptive
deficits
could
be
that
the
impingement
group
did
not
have
def-
icits
related
with
slow-adapting
mechanoreceptors
which
are
present
in
passive
restraints
and
bursa.
Although
significant
differences
between
case
group
and
control
groups
were
not
found,
a
post
hoc
power
analysis
indicated
that
this
comparison
had
less
than
40%
power.
Because
of
the
limited
sample
size
of
each
group,
we
cannot
eliminate
the
risk
of
Type
II
statistical
error.
Nevertheless,
it
is
difficult
to
have
committed
this
type
of
error
because
differences
between
the
means
of
the
groups
in
the
variables
(PMR,
PLR,
and
ALR)
that
have
not
reached
statisti-
cal
significance
were
small
enough
not
to
be
clinically
relevant.
JPS
error
scores
ranging
from
to
on
healthy
subjects
were
not
considered
to
be
of
clinical
significance
by
Dover
et
al
(2003).
Despite
this,
we
should
encourage
other
studies
to
calculate
the
reliability
of the
measures
to
better
support
the
results.
It
is
important
to
highlight
that
possible
influences
of
cutaneous
cues
from
the
contact
of
the
upper
limb
with
the
limb-support
pad
of
the
dynamometer
may
have
resulted
in
inadequate
isolation
of
propriocep-
tion.
Also,
one
should
note
that
the
speed
used
to
show
the
target
angles
for
the
subjects
was
the
same
used
during
the
respective
tests.
This
may
have
allowed
the
subjects
to
use
time
to
achieve
the
target
angle.
Another
issue
to
be
considered
is
the
passive
protocol
which
could
have
involved
some
muscle
con-
traction
due
to
subject's
apprehension.
Finally,
as
the
impingement
occurs
at
different
points
in
the
range
of
motion
and
affects
different
portions
of
the
rotator
cuff,
future
investigations
are
required
to
evaluate
JPS
in
different
target
angles
during
other
shoulder
movements
such
as
abduction,
for
example,
and
also
in
later
stages
of
the
disease.
Because
of
the
lack
of
consistency
among
studies,
the
question
still
remains
if
JPS
is
altered
in
subjects
with
SIS.
Further
research
about
sensory-motor
control
in
subjects
with
SIS
is
necessary
to
understand
the
mechanisms
involved
in
SIS,
and
to
help
to
refine
rehabilitation
programs.
CONCLUSION
The
results
of
this
study
showed
that
JPS
is
preserved
in
female
assembly
workers
with
SIS
during
medial
and
lateral
shoulder
rotations.
However,
alterations
may
be
observed
during
AMR
in
asymptomatic
female
assembly
workers
exposed
to
overhead
activities.
ACKNOWLEDGMENTS
The
authors
are
grateful
to
FAPESP
and
CNPq
for
the
research
fellowships.
The
authors
are
deeply
grate-
ful
to
the
industry
for
allowing
its
execution.
Declaration
of
interest:
The
authors
report
no
conflicts
of
interest.
The
authors
alone
are
responsible
for
the
content
and
writing
of
the
paper.
REFERENCES
Allegrucci
M,
Whitney
SL,
Lephart
SM,
Irrgang
J,
Fu
FH
1995
Shoulder
kinesthesia
in
healthy
unilateral
athletes
participating
in
upper
extremity
sports.
Journal
of
Orthopaedic
Sports
Phys-
ical
Therapy
21:
220-226
Aydin
T,
Yildiz
Y,
Yanmis
I,
Yildiz
C,
Kalyon
TA
2001
Shoulder
proprioception:
A
comparison
between
the
shoulder
joint
in
healthy
and
surgically
repaired
shoulders.
Archives
of
Orthopae-
dic
and
Trauma
Surgery
121:
422-425
Baker
V,
Bernell
K,
Stillman
B,
Cowan
S,
Crossley
K
2002
Abnor-
mal
knee
joint
position
sense
in
individuals
with
patellofemoral
pain
syndrome.
Journal
of
Orthopaedic
Research
20:
208-214
Bandholm
T,
Rasmussen
L,
Aagaard
P,
Jensen
BR,
Diederichsen
L
2006
Force
steadiness,
muscle
activity,
and
maximal
muscle
strength
in
subjects
with
subacromial
impingement
syndrome.
Muscle
and
Nerve
34:
631-639
Barden
JM,
Balyk
R,
Raso
VJ,
Moreau
M,
Bagnall
K
2004
Dynamic
upper
limb
proprioception
in
multidirectional
shoulder
instabil-
ity.
Clinical
Orthopaedics
and
Related
Research
420:
181-189
Calis
M,
Akgun
K,
Birtane
M,
Karacan
I,
Calis
H,
Tuzun
F
2000
Diagnostic
values
of
clinical
diagnostic
tests
in
subacromial
impingement
syndrome.
Annals
of
the
Rheumatic
Diseases
59:
44-47
Camargo
PR,
Haik
MN,
Filho
RB,
Mattiello-Rosa
SM,
Salvini
TF
2007
Pain
in
workers
with
shoulder
impingement
syndrome:
An
assessment
using
the
DASH
and
McGill
pain
questionnaires.
Revista
Brasileira
de
Fisioterapia
11:
161-167
Camargo
PR,
Haik
MN,
Filho
RB,
Mattiello-Rosa
SM,
Salvini
TF
2008
Bilateral
deficits
in
muscle
contraction
parameters
during
shoulder
scaption
in
patients
with
unilateral
subacromial
impin-
gement
syndrome.
Isokinetics
and
Exercise
Science
16:
93-99
Camargo
PR,
Avila
MA,
Oliveira
AB,
Asso
NA,
Benze
BG,
Salvini
TF
2009
Shoulder
abduction
torque
steadiness
is
preserved
in
subacromial
impingement
syndrome.
European
Journal
of
Applied
Physiology
106:
381-387
Carpenter
JE,
Blasier
RB,
Pellizzon
GG
1998
The
effects
of
muscle
fatigue
on
shoulder
joint
position
sense.
American
Journal
of
Sports
Medicine
26:
262-265
Cools
AM,
Witvrouw
EE,
Mahieu
NM,
Danneels
LA
2005
Isoki-
netic
scapular
muscle
performance
in
overhead
athletes
with
and
without
impingement
symptoms.
Journal
of
Athletic
Train-
ing
40:
104-110
Cools
AM,
Gambier
DC,
Witvrouw
EE
2008
Screening
the
ath-
lete's
shoulder
for
impingement
symptoms:
A
clinical
reasoning
Copyright
©
Informa
Healthcare
USA,
Inc.
Physiotherapy
Theory
and
Practice
49
algorithm
for
early
detection
of
shoulder
pathology.
British
Journal
of Sports
Medicine
42:
628-635
Dover
G,
Powers
ME
2003
Reliability
of
joint
position
sense
and
force-reproduction
measures
during
internal
and
external
rotation
of
the
shoulder.
Journal
of
Athletic
Training
38:
304-310
Dover
G,
Powers
ME
2004
Cryotherapy
does
not
impair
shoulder
joint
position
sense.
Archives
of
Physical
Medicine
and
Rehabi-
litation
85:
1241-1246
Dover
GC,
Kaminski
TW,
Meister
K,
Powers
ME,
Horodyski
M
2003
Assessment
of
shoulder
proprioception
in
the
female
soft-
ball
athlete.
American
Journal
of
Sports
Medicine
31:
431-437
Dupuis
C,
Toumy-Chollet
C,
Delaruea
Y,
Beret-Blanquarta
F
2004
Influence
of
baseball
practice
on
strength
ratios
in
shoulder
rotator
muscles:
A
new
position
for
isokinetic
assessment.
Isoki-
netics
and
Exercise
Science
12:
149-157
Ellenbecker
TS,
Davies
GJ
2000
The
application
of
isokinetics
in
testing
and
rehabilitation
of
the
shoulder
complex.
Journal
of
Athletic
Training
35:
338-350
Frost
P,
Andersen
JH
1999
Shoulder
impingement
syndrome
in
relation
to
shoulder
intensive
work.
Occupational
and
Environ-
mental
Medicine
56:
494-498
Gandevia
SC,
Hall
LA,
McCloskey
DI,
Potter
EK
1983
Propriocep-
tive
sensation
at
the
terminal
joint
of
the
middle
finger.
Journal
of
Physiology
335:
507-517
Gerber
C,
Krushell
RJ
1991
Isolated
rupture
of
the
subscapularis
muscle
Clinical
features
in
16
cases.
Journal
of
Bone
and
Joint
Surgery
(Br)
73:
389-394
Goodwin
GM,
McCloskey
DI,
Matthews
PB
1972
The
contri-
bution
of
muscle
afferents
to
kinesthesia
shown
by
vibration
induced
illusions
of
movement
and
by
the
effects
of
paralysing
joint
afferents.
Brain
95:
705-748
Hawkins
RJ,
Kennedy
JC
1980
Impingement
syndrome
in
athletes.
American
Journal
of
Sports
Medicine
8:
151-158
Janwantanakul
P,
Magarey
ME,
Jones
MA,
Dansie
BR
2001
Vari-
ation
in
shoulder
position
sense
at
mid
and
extreme
range
of
motion.
Archives
of
Physical
Medicine
and
Rehabilitation
82:
840-844
Jobe
FW,
Moynes
DR
1982
Delineation
of
diagnostic
criteria
and
a
rehabilitation
program
for
rotator
cuff
injuries.
American
Journal
of
Sports
Medicine
10:
336-339
Leclerc
A,
Chastang
JF,
Niedhammer
I,
Landre
MF,
Roquelaure
Y
2004
Study
group
on
repetitive
work.
Incidence
of
shoulder
pain
in
repetitive
work.
Occupational
and
Environmental
Medicine
61:
39-44
Lee
H,
Liau
B,
Cheng
CK,
Tan
CM,
Shih
JT
2003
Evaluation
of
shoulder
proprioception
following
muscle
fatigue.
Clinical
Bio-
mechanics
18:
843-847
Lephart
SM,
Fu
FH
2000
(eds)
Proprioception
and
Neuromuscular
Control
in
Joint
Stability.
Champaign:
Human
Kinetics
Lephart
SM,
Myers
JB,
Bradley
JP,
Fu
FH
2002
Shoulder
proprio-
ception
and
function
following
thermal
capsulorraphy.
Arthro-
scopy
18:
770-778
Lean
J,
Crenshaw
AG,
Djupsjobacka
M,
Pedersen
J,
Johansson
H
2000
Position
sense
testing:
Influence
of
starting
position
and
type
of
displacement.
Archives
of
Physical
Medicine
and
Reha-
bilitation
81:
592-597
Ludewig
PM,
Cook
TM
2000
Alterations
in
shoulder
kinematics
and
associated
muscle
activity
in
people
with
symptoms
of
shoulder
impingement.
Physical
Therapy
80:
276-291
Machner
A,
Merk
H,
Becker
R,
Rohkohl
K,
Wissel
H,
Pap
G
2003
Kinesthetic
sense
of
the
shoulder
in
patients
with
impingement
syndrome.
Acta
Orthopaedica
Scandinavica
74:
85-88
Mattiello-Rosa
SM,
Camargo
PR,
Santos
AA,
Padua
M,
Reiff
RB,
Salvini
TF
2008
Abnormal
isokinetic
time-to-peak
torque
of
the
medial
rotators
of
the
shoulder
in
subjects
with
impingement
syn-
drome.
Journal
of
Shoulder
and
Elbow
Surgery
17
(Suppl.
1):
p54S-60S
Michener
LA,
McClure
PW,
Karduna
AR
2003
Anatomical
and
biomechanical
mechanisms
of
subacromial
impingement
syn-
drome.
Clinical
Biomechanics
18:
369-379
Myers
JB,
Wassinger
CA,
Lephart
SM
2006
Sensorimotor
contri-
bution
to
shoulder
instability:
Effect
of
injury
and
rehabilitation.
Manual
Therapy
11:
197-201
Neer
CS
1972
Anterior
acromioplasty
for
the
chronic
impingement
syndrome
in
the
shoulder:
A
preliminary
report.
Journal
of
Bone
and
Joint
Surgery
(Am)
54:
41-50
Neer
CS,
Foster
CR
1980
Inferior
capsular
shift
for
involuntary
inferior
and
multidirectional
instability
of
the
shoulder.
A
pre-
liminary
report.
Journal
of
Bone
and
Joint
Surgery
(Am)
62:
897-908
Niessen
MH,
Veeger
DH,
Koppe
PA,
Konijnenbelt
MH,
van
Dieen
J,
Janssen
TW
2008
Proprioception
of
the
shoulder
after
stroke.
Archives
of
Physical
Medicine
and
Rehabilitation
89:
333-338
Phadke
V,
Camargo
PR,
Ludewig
PM
2009
Scapular
and
rotator
cuff
muscle
function
during
arm
elevation:
A
review
of
normal
function
and
alterations
with
shoulder
impingement.
Revista
Brasileira
de
Fisioterapia
13:
1-9
Potzl
W,
Thorwesten
L,
Gotze
C,
Garmann
S,
Steinbeck
J
2004
Proprioception
of
the
shoulder
joint
after
surgical
repair
for
in-
stability.
American
Journal
of Sports
Medicine
32:
425-430
Proske
U
2006
Kinesthesia:
The
role
of
muscle
receptors.
Muscle
and
Nerve
34:
545-558
Riemann
BL,
Lephart
SM
2002a
The
sensorimotor
system,
part
I:
The
physiologic
basis
of
functional
joint
stability.
Journal
of
Ath-
letic
Training
37:
71-79
Riemann
BL,
Lephart
SM
2002b
The
sensorimotor
system,
part
II:
The
role
of
proprioception
in
motor
control
and
functional
joint
stability.
Journal
of
Athletic
Training
37:
80-84
Rowe
CR,
Zarins
B
1981
Recurrent
transient
subluxation
of
the
shoulder.
Journal
of
Bone
and
Joint
Surgery
(Am)
63:
863-872
Safran
MR,
Borsa
PA,
Lephart
SM,
Fu
FH,
Warner
BP
2001
Shoulder
proprioception
in
baseball
pitchers.
Journal
of
Shoulder
and
Elbow
Surgery
10:
438-444
Smith
IL,
Crawford
M,
Proske
U,
Taylor
JL,
Gandevia
SC
2009
Signals
of
motor
command
bias
joint
position
sense
in
the
pres-
ence
of
feedback from
proprioceptors.
Journal
of
Applied
Physi-
ology
106:
950-958
Suprak
D
2011
Shoulder
joint
position
sense
is
not
enhanced
at
end
range
in
an
unconstrained
task.
Human
and
Movement
Science
30:
424-435
Suprak
DN,
Osternig
LR,
van
Donkelaar
P,
Karduna
AR
2006
Shoulder
joint
position
sense
improves
with
elevation
angle
in
a
novel,
unconstrained
task.
Journal
of
Orthopaedic
Research
24:
559-568
Suprak
DN,
Osternig
LR,
van
Donkelaar
P,
Karduna
AR
2007
Shoulder
joint
position
sense
improves
with
external
load.
Journal
of
Motor
Behavior
39:
517-525
Sorensen
AK,
Jorgensen
U
2000
Secondary
impingement
in
the
shoulder.
An
improved
terminology
in
impingement.
Scandinavian
Journal
of
Medicine
and
Science
in
Sports
10:
266-278
Swanik
KA,
Lephart
SM,
Swanik
CB,
Lephart
SP,
Stone
DA,
Fu
FH
2002
The
effects
of
shoulder
plyometric
training
on
proprio-
ception
and
selected
muscle
performance
characteristics.
Journal
of
Shoulder
and
Elbow
Surgery
11:
579-586
Tibone
JE,
Fechter
J,
Kao
JT
1997
Evaluation
of
a
proprioception
pathway
in
patients
with
stable
and
unstable
shoulders
with
cor-
tical
evoked
potentials.
Journal
of
Shoulder
and
Elbow
Surgery
6:
440-443
Physiotherapy
Theory
and
Practice
50
Haik
et
al.
Vangsness
CT,
Ennis
M
1992
Neural
anatomy
of
the
human
glenoid
and
shoulder
ligaments.
In:
Proceedings
of
the
59th
annual
meeting
of
the
American
Academy
of
Orthopedic
Sur-
geons,
Washington,
DC
Venturini
PJF,
Oliveira
LA,
Mattiello-Rosa
SMG
2002
Avaliagao
isocinetica
dos
parametros
pico
de
torque
e
potencia
no
movimento
de
flekao
do
ombro
de
individuos
por-
tadores
de
DORT
grau
I.
Revista
Brasileira
de
Fisioterapia
6:
55-62
Voight
ML,
Hardin
JA,
Blackburn
TA,
Tippett
S,
Canner
GC
1996
The
effects
of
muscle
fatigue
on
and
the
relationship
of
arm
dominance
to
shoulder
proprioception.
Journal
of
Orthopaedic
Sports
Physical
Therapy
23:
348-352
Walsh
LD,
Smith
JL,
Gandevia
SC,
Taylor
JL
2009
The
combined
effect
of
muscle
contraction
history
and
motor
commands
on
human
position
sense.
Experimental
Brain
Research
195:
603-610
Warner
JJP,
Micheli
LJ,
Arslanian
LE,
Kennedy
J,
Kennedy
R
1990
Patterns
of
flexibility,
laxity,
and
strength
in
normal
shoulders
and
shoulders
with
instability
and
impingement.
American
Journal
of Sports
Medicine
18:
366-375
Warner
JJP,
Lephart
S,
Fu
FH
1996
Role
of
proprioception
in
pathoetiology
of
shoulder
instability.
Clinical
Orthopaedics
and
Related
Research
330:
35-39
Wassinger
CA,
Myers
JB,
Gam
JM,
Conley
KM,
Lephart
SM
2007
Proprioception
and
throwing
accuracy
in
the
dominant
shoulder
after
cryotherapy.
Journal
of
Athletic
Training
42:
84-89
Winter
JA,
Allen
TJ,
Proske
U
2005
Muscle
spindle
signals
combine
with
the
sense
of
effort
to
indicate
limb
position.
Journal
of
Physiology
568:
1035-1046
Zanca
GG,
Camargo
PR,
Oliveira
AB,
Serrao
PRMS,
Mattiello-
Rosa
SMG
2010
Isometric
medial
and
lateral
rotations
torque
steadiness
in
female
workers
with
shoulder
impingement.
Isoki-
netics
and
Exercise
Science
18:
115-118
Copyright
©
Informa
Healthcare
USA,
Inc.