Altered Cocontraction Patterns of Humeral Head Depressors in Patients with Subacromial Pain Syndrome: A Cross-sectional Electromyography Analysis

Celeste L Overbeek, Arjen Kolk, Jurriaan H de Groot, Cornelis P J Visser, Peer van der Zwaal, Axel Jens, Jochem Nagels, Rob G H H Nelissen, Celeste L Overbeek, Arjen Kolk, Jurriaan H de Groot, Cornelis P J Visser, Peer van der Zwaal, Axel Jens, Jochem Nagels, Rob G H H Nelissen

Abstract

Background: In approximately 29% to 34% of all patients with subacromial pain syndrome (SAPS) there is no anatomic explanation for symptoms, and behavioral aspects and/or central pain mechanisms may play a more important role than previously assumed. A possible behavioral explanation for pain in patients with SAPS is insufficient active depression of the humerus during abduction by the adductor muscles. Although the adductor muscles, specifically the teres major, have the most important contribution to depression of the humerus during abduction, these muscles have not been well studied in patients with SAPS.

Questions/purposes: Do patients with SAPS have altered contraction patterns of the arm adductors during abduction compared with asymptomatic people?

Methods: SAPS was defined as nonspecific shoulder pain lasting for longer than 3 months that could not be explained by specific conditions such as calcific tendinitis, full-thickness rotator cuff tears, or symptomatic acromioclavicular arthritis, as assessed with clinical examination, radiographs, and magnetic resonance arthrography. Of 85 patients with SAPS who met the prespecified inclusion criteria, 40 were eligible and agreed to participate in this study. Thirty asymptomatic spouses of patients with musculoskeletal complaints, aged 35 to 60 years, were included; the SAPS and control groups were not different with respect to age, sex, and hand dominance. With electromyography, we assessed the contraction patterns of selected muscles that directly act on the position of the humerus relative to the scapula (the latissimus dorsi, teres major, pectoralis major, and deltoid muscles). Cocontraction was quantified through the activation ratio ([AR]; range, -1 to 1). The AR indicates the task-related degree of antagonist activation relative to the same muscle's degree of agonist activation, equaling 1 in case of sole agonist muscle activation and equaling -1 in case of sole antagonistic activation (cocontraction). We compared the AR between patients with SAPS and asymptomatic controls using linear mixed-model analyses. An effect size of 0.10 < AR < 0.20 was subjectively considered to be a modest effect size.

Results: Patients with SAPS had a 0.11 higher AR of the teres major (95% CI, 0.01-0.21; p = 0.038), a 0.11 lower AR of the pectoralis major (95% CI, -0.18 to -0.04; p = 0.003), and a 0.12 lower AR of the deltoid muscle (95% CI, -0.17 to -0.06; p < 0.001) than control participants did. These differences were considered to be modest. With the numbers available, we found no difference in the AR of the latissimus dorsi between patients with SAPS and controls (difference = 0.05; 95% CI, -0.01 to 0.12; p = 0.120).

Conclusions: Patients with SAPS showed an altered adductor cocontraction pattern with reduced teres major activation during abduction. The consequent reduction of caudally directed forces on the humerus may lead to repetitive overloading of the subacromial tissues and perpetuate symptoms in patients with SAPS. Physical therapy programs are frequently effective in patients with SAPS, but targeted approaches are lacking. Clinicians and scientists may use the findings of this study to assess if actively training adductor cocontraction in patients with SAPS to unload the subacromial tissues is clinically effective. The efficacy of training protocols may be enhanced by using electromyography monitoring.

Level of evidence: Level II, prognostic study.

Conflict of interest statement

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Figures

Fig. 1
Fig. 1
A flow diagram of the participant inclusion process is shown.
Fig. 2
Fig. 2
The activation ratios of four shoulder muscles in patients with SAPS and controls are shown. LD = latissimus dorsi; TM = teres major; PM = pectoralis major; DM = deltoid muscle

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