Presentación sobre la Evidencia actual en la Rehabilitación del Hombro Doloroso para el curso EVIGRA 2014.

1. Evidencias
en
Rehabilitación
del
Hombro
Doloroso
Ángel León Valenzuela!
angel.leon.valenzuela@gmail.com!
@Angel_Leon_!
UGC
Intercentros-­‐Interniveles
HHUU
de
Puerto
Real
y
Puerta
del
Mar
(Cádiz)
EVIGRA 2014Granada 19-22 Febrero

2. Presentar las evidencias de
mayor calidad y más
actualizadas!

3. Compartir y difundir!

4. #Evigra!
!
@Angel_Leon_!
!

5. Niveles de evidencia!
Nivel
I!
Evidencia
obtenida
de
estudios
diagnós4cos,
prospec4vos
o
ECA
de
ALTA
calidad!
Nivel
II!
Evidencia
obtenida
de
estudios
diagnós4cos,
prospec4vos
o
ECA
de
BAJA
calidad!
Nivel
III!
Evidencia
obtenida
de
estudios
CASOS-­‐CONTROLES
o
RETROSPECTIVOS!
Nivel
IV! Evidencia
obtenida
de
SERIES
DE
CASOS!
Nivel
V! Evidencia
obtenida
de
OPINIÓN
DE
EXPERTOS!

6. Grados de recomendación!
A! FUERTE! Una mayoría de estudios nivel I!
B! MODERADA!
Una mayoría de estudios de nivel II o un único
estudio nivel I, apoyan la recomendación !
C! DEBIL!
Un solo estudio nivel II o una mayoría de estudios
de nivel III y IV apoyan la recomendación !
D! CONFLICTIVA!
La recomendación se basa en estos estudios
contradictorios !
E! TEÓRICA!
Una mayoría de estudios en animales o de
cadáveres o estudios de investigación en ciencias
básicas apoyan esta conclusión!
F!
OPINIÓN DE
EXPERTOS!
Prácticas basadas en la experiencia clínica!

7. HOMBRO DOLOROSO!
• Cuadro clínico caracterizado por dolor
localizado a nivel del hombro, en
cualquiera de sus 3 articulaciones
(glenohumeral, acromioclavicular y
esternoclavicular ) y/o tejidos blandos
circundantes !
• Prevalencia estimada: 16% al 34%!

8. HOMBRO
DOLOROSO
PATOLOGÍA
EXTRÍNSECA
• Trastornos cervicales!
• Trastornos nerviosos: radiculopatía,
lesión plexo braquial, síndrome de
Parsonnage-Turner o neuralgia
amiotrófica.!
• Trastornos inflamatorios:
polimialgia reumática. !
• Síndrome de Dolor Regional
Complejo!
• Dolor miofascial!
• Lesiones torácicas o costales!
• Dolor referido visceral !

9. HOMBRO
DOLOROSO
PATOLOGÍA
INTRÍNSECA

10. HOMBRO
DOLOROSO
PATOLOGÍA
INTRÍNSECA
!
• Capsulitis adhesiva!
• Lesiones Manguito!
• Inestabilidad!
!
PATOLOGÍA
EXTRÍNSECA
• Trastornos cervicales!
• Trastornos nerviosos: radiculopatía,
lesión plexo braquial, síndrome de
Parsonnage-Turner o neuralgia
amiotrófica.!
• Trastornos inflamatorios:
polimialgia reumática. !
• Síndrome de Dolor Regional
Complejo!
• Dolor miofascial!
• Lesiones torácicas o costales!
• Dolor referido visceral !

11. CAPSULITIS ADHESIVA!

12. Health Technology Assessment 2012; Vol. 16: No. 11
ISSN 1366-5278
Health Technology Assessment
NIHR HTA programme
www.hta.ac.uk
March 2012
10.3310/hta16110
Management of frozen shoulder:
a systematic review and
cost-effectiveness analysis
E Maund, D Craig, S Suekarran, AR Neilson,
K Wright, S Brealey, L Dennis, L Goodchild,
N Hanchard, A Rangan, G Richardson,
J Robertson and C McDaid
H
I
A
G
L
E
C
C
C
C
C
A
R
H
Clinical Practice Guidelines
MARTIN J. KELLEY, DPT • MICHAEL A. SHAFFER, MSPT • JOHN E. KUHN, MD • LORI A. MICHENER, PT, PhD
AMEE L. SEITZ, PT, PhD • TIMOTHY L. UHL, PT, PhD • JOSEPH J. GODGES, DPT, MA • PHILIP W. MCCLURE, PT, PhD
Shoulder Pain and Mobility
Deficits: Adhesive Capsulitis
Clinical Practice Guidelines Linked to the
International Classification of Functioning,
Disability, and Health From the Orthopaedic Section
of the American Physical Therapy Association
J Orthop Sports Phys Ther 2013;43(5):A1-A31. doi:10.2519/jospt.2013.0302
REVIEWERS: Roy D. Altman, MD • John DeWitt, DPT • George J. Davies, DPT, MEd, MA
Todd Davenport, DPT • Helene Fearon, DPT • Amanda Ferland, DPT • Paula M. Ludewig, PT, PhD • Joy MacDermid, PT, PhD
James W. Matheson, DPT • Paul J. Roubal, DPT, PhD • Leslie Torburn, DPT • Kevin Wilk, DPT
For author, coordinator, contributor, and reviewer affiliations, see end of text. Copyright ©2013 Orthopaedic Section, American Physical Therapy Association (APTA), Inc,
and the Journal of Orthopaedic & Sports Physical Therapy. The Orthopaedic Section, APTA, Inc, and the Journal of Orthopaedic & Sports Physical Therapy consent to
the reproduction and distribution of these guidelines for educational purposes. Address correspondence to: Joseph Godges, DPT, ICF Practice Guidelines Coordinator,
Orthopaedic Section, APTA, Inc, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: icf@orthopt.org
RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3
METHODS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4
CLINICAL GUIDELINES:
Impairment/Function-Based Diagnosis . . . . . . . . . . . . . . . . . . A6
CLINICAL GUIDELINES:
Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A14
CLINICAL GUIDELINES:
Interventions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A16
SUMMARY OF RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . A26
AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS. . . . . . A27
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A28

13. Definición!
Restricción funcional del balance articular
pasivo y activo del hombro, sin lesiones
remarcables en estudios radiográficos,
excepto por la posible presencia de
osteopenia o tendinosis cálcica.!
J Shoulder Elbow Surg. 2011 Mar;20(2):322-5. Frozen shoulder: a
consensus definition. Zuckerman JD, Rokito A.!

14. Clasificación!
A. PRIMARIO!
B. SECUNDARIO:!
A. Intrínseco: !
– Ej.: Tendinopatía del manguito, Tendinosis bicipital, Tendinopatía cálcica!
B. Extrínseco:!
– Cx mama, Patología cervical, fractura previa, ACV, etc.!
C. Sistémico:!
– Ej.: DM, hipotiroidismo, etc.!

15. Factores de riesgo!
Richard J Murphy and Andrew J Carr Shoulder pain Clinical Evidence 2010 !
q Sexo
femenino
q Edad
avanzada
q Trauma4smo
de
hombro
q Cirugía
q Diabetes
q Trastornos
cardiorrespiratorios
q Accidente
cerebrovascular
q Enfermedad
del
4roides

16. Hª natural!
1. Congelación (FREEZING)!
– Aumento progresivo del dolor y disminución de la
amplitud de movimiento. 6 semanas a 9 meses.!
2. Congelado (FROZEN)!
– Mejora el dolor, pero la rigidez permanece. 4 a 6
meses.!
3. Deshielo (THAWING)!
– Mejoría lenta de la movilidad. 6 meses 3 años.!

17. Diagnóstico!

18. Exploración física!
Diagnóstico fundamentalmente clínico:!
– Perdida BA activo y pasivo!
– Mayor afectación rotaciones (especialmente
RE)!
– Patrón capsular a la exploración.!
J Shoulder Elbow Surg. 2011 Apr;20(3):502-14. doi: 10.1016/j.jse.2010.08.023. Epub 2010
Dec 16.Current review of adhesive capsulitis.Hsu JE, Anakwenze OA, Warrender WJ,
Abboud JA.!

19. Diagnóstico por imagen!
• No indicado de rutina.!
• Signos RMN y artroRMN:!
– Estrechamiento lig.
Coracohumeral (también en
ecografía) !
– Contracción capsular:
disminución volumen!
– Estrechamiento a nivel receso
axilar.!
• PLoS One. 2011;6(12):e28704. MRI findings for frozen
shoulder evaluation: is the thickness of the coracohumeral
ligament a valuable diagnostic tool?Li JQ, Tang et al!
• J Shoulder Elbow Surg. 2011 Apr;20(3):502-14. doi: 10.1016/
j.jse.2010.08.023. Epub 2010 Dec 16.Current review of
adhesive capsulitis.Hsu JE, Anakwenze OA, Warrender WJ,
Abboud JA.!

20. Tratamiento!

21. Esteroides orales!
Proporcionan beneficios significativos a
corto plazo ( < 6 semanas) del dolor, el
arco de movilidad del hombro y la función. !
!
• Maund E, et al . Health Technol Assess. 2012;16(11):1-264 Management of frozen shoulder: a systematic review and
cost-effectiveness analysis.!
!
II!

22. Infiltraciones esteroides!
• Beneficios significativos a corto plazo y medio
plazo ( < 6 semanas) del dolor, BA, función y
discapacidad.!
• No diferencias significativas en la Calidad de
Vida.!
• Más efectivo que la FT a corto y largo plazo !
• Combinada con FT se añade beneficio a los
tratamientos individualizados.!
• Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Maund E, et al . Health
Technol Assess. 2012;16(11):1-264 !
• Shoulder pain and mobility deficits: Adhesive Capsulitis. Kelley et al. J Orthop Sport Phys Ther 2013;43(5):A1-A31!
A!

23. Infiltraciones hialurónico!
• 3 ECA !
• Mejora el BA, función y dolor a corto plazo. !
• Sus resultados son similares a los de la
infiltración con corticoides!
• Alto riesgo de sesgo!
• Maund
E,
et
al
.
Health
Technol
Assess.
2012;16(11):1-­‐264
Management
of
frozen
shoulder:
a
systema4c
review
and
cost-­‐effec4veness
analysis.
D!

24. Acupuntura!
• 3 ECA baja calidad (sólo 1
control con placebo)!
• Reducción del dolor Vs
placebo (<4 semanas)!
• Importante heterogeneidad!
• Alto riesgo de sesgo!
• Maund E, et al . Health Technol Assess. 2012;16(11):1-264
Management of frozen shoulder: a systematic review and cost-
effectiveness analysis.!
No pruebas
suficientes de
eficacia !
III!

25. Laser!
• Eslamian F, Shakouri SK, Ghojazadeh M, Nobari OE, Eftekharsadat B. Effects of low-level laser
therapy in combination with physiotherapy in the management of rotator cuff tendinitis. Lasers Med
Sci. 2012 Sep;27(5):951-8. doi:10.1007/10103-011-1001-3.!
• M M Favejee, B M A Huisstede, B W Koes Frozen shoulder: the effectiveness of conservative and
surgical interventions—ti–56. doi:10.1136/bjsm.2010.071431!
• Mejoría significativa a
corto plazo del dolor y
función.!
• No diferencias
significativas en el
Balance Articular !
!
• Conflicto de Intereses ?!
I!

26. Fisioterapia!
• 12 ECA que comparan distintas
técnicas de tratamiento.!
• Importante heterogeneidad!
• Mayor evidencia de la onda
corta y de movilizaciones de
alto grado (Grados 3-4 de
Maitland)!
• Resultados inferiores a corto
plazo que la infiltración!
• Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Maund E, et al . Health
Technol Assess. 2012;16(11):1-264 !
• Shoulder pain and mobility deficits: Adhesive Capsulitis. Kelley et al. J Orthop Sport Phys Ther 2013;43(5):A1-A31!
C!

27. Ejercicio!
• 5 ECA.!
• No definición intensidad, duración,
frecuencia etc!
• Sólo uno define ejercicios!
• Instruir a pacientes en ejercicios de
estiramiento específicos. La intensidad
debe ser determinada según estado inicial
del paciente.!
B!
• Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Maund E, et al . Health
Technol Assess. 2012;16(11):1-264 !
• Shoulder pain and mobility deficits: Adhesive Capsulitis. Kelley et al. J Orthop Sport Phys Ther 2013;43(5):A1-A31!

28. Bloqueo del n.
supraescapular!
• Beneficios significativos a corto
plazo ( 3 meses) del dolor !
• Los resultados mejoran cuando
se aplica con técnica guiada
electromiograficamente vs guía
anatómica. !
• Mayor mejoría del dolor y BA
que con infiltraciones
intrarticulares !
M M Favejee, B M A Huisstede, B W Koes Frozen shoulder: the
effectiveness of conservative and surgical interventions—ti–56. doi:
10.1136/bjsm.2010.071431!
II!

29. Bloqueo del n.
supraescapular!
• Beneficios significativos a corto
plazo ( 3 meses) del dolor !
• Los resultados mejoran cuando
se aplica con técnica guiada
electromiograficamente vs guía
anatómica. !
• Mayor mejoría del dolor y BA
que con infiltraciones
intrarticulares !
M M Favejee, B M A Huisstede, B W Koes Frozen shoulder: the
effectiveness of conservative and surgical interventions—ti–56. doi:
10.1136/bjsm.2010.071431!
PENDIENTES
ACTUALIZACIÓN
DE
LA
COCHRANE
II!

30. Radiofrecuencia!
• Series de casos!
• Mejoría del dolor y del BA!
• Resultados se mantienen a
medio plazo!
Huang CC, Tsao SL, Cheng CY, Hsin MT, Chen CM. Treating frozen shoulder with ultrasound-guided pulsed mode
radiofrequency lesioning of the suprascapular nerve: two cases. Pain Med. 2010 Dec;11(12):1837-40. doi:!
10.1111/j.1526-4637.2010.00970.x. Epub 2010 Oct 28. PubMed PMID: 21040432.!
IV!

31. Manipulación bajo
anestesia!
• No diferencias entre la
manipulación bajo
anestesia y tratamientos
conservadores (RHB,
infiltraciones…)!
• Importantes limitaciones:!
– Ensayos muy heterogéneos. !
– Recogida de resultados!
Health Technol Assess. 2012;16(11):1-264. doi: 10.3310/hta16110.!
Management of frozen shoulder: a systematic review and cost-effectiveness analysis.!
Maund E, Craig D, Suekarran S, Neilson A, Wright K, Brealey S, Dennis L, Goodchild L, Hanchard N, Rangan A,
Richardson G, Robertson J, McDaid C!
C!

32. Hidrodilatación!
• 1 ECA y casos controles!
• No diferencia significativa con
la manipulación bajo
anestesia.!
• No diferencia al comparar con
corticoides sólos!
• Maund E, et al . Health Technol Assess. 2012;16(11):1-264 Management of
frozen shoulder: a systematic review and cost-effectiveness analysis.!
• Quraishi NA, Johnston P, Bayer J, Crowe M, Chakrabarti AJ. Thawing the
frozen shoulder. A randomised trial comparing manipulation under
anaesthesia with hydrodilatation. J Bone Joint Surg Br. 2007 Sep;89(9):
1197-200. PubMed PMID:17905957.!
• Tveitå EK, Tariq R, Sesseng S, Juel NG, Bautz-Holter E. Hydrodilatation,
corticosteroids and adhesive capsulitis: a randomized controlled trial. BMC
Musculoskelet Disord. 2008 Apr 19;9:53. doi: 10.1186/1471-2474-9-53.
PubMed PMID:18423042; PubMed Central PMCID: PMC2374785!
III!

33. Distensión
artrográfica!
Rev. COCHRANE:!
– Existe EVIDENCIA MODERADA
de que proporciona beneficios a
corto plazo para el dolor, la
amplitud de movimiento y la
función en la capsulitis adhesiva. !
– Los resultados mejoran si se
realiza fisioterapia posteriormente.!
• Maund E, et al . Health Technol Assess. 2012;16(11):1-264
Management of frozen shoulder: a systematic review and cost-
effectiveness analysis.!
• Buchbinder R, Green S, Youd JM, Johnston RV, Cumpston M.
Distensión artrográfica para la capsulitis adhesiva En: La Biblioteca
Cochrane Plus, 2008 Número 4!
Rev.
HTA:
• No
existe
evidencia
consistente
(Riesgo
de
sesgo
en
la
recogida
de
resultados)
D!

34. Liberación
capsular! • 1 Casos-Control (y 2 series
de casos)!
• Poco beneficio de la
liberación capsular +/-
Manipulación bajo anestesia. !
• Grant JA, Schroeder N, Miller BS, Carpenter JE. Comparison of
manipulation and arthroscopic capsular release for adhesive capsulitis: a
systematic review. J Shoulder Elbow Surg. 2013 Aug;22(8):1135-45. doi:
10.1016/j.jse.2013.01.010. Epub 2013 Mar 17!
• Maund E, et al . Health Technol Assess. 2012;16(11):1-264 Management
of frozen shoulder: a systematic review and cost-effectiveness analysis.!
III!

35. Movilización bajo anestesia/ Distensión artrográfica / Liberación
capsular!
Bloqueo n. Supraescapular / Hidrodilatación!
Infiltración con esteroides + FT!
Laser / Onda corta! Ejercicio terapéutico! Movilizaciones Alto Grado!
1ª Infiltración con esteroides + Programa domiciliario!
Propuesta tratamiento!

36. PATOLOGÍA DEL MANGUITO!

37. • Pinzamiento mecánico del
tendón del manguito rotador
debajo de la parte anteroinferior
del acromion, por uno o más de
los diferentes componentes del
arco acromial: acromion,
articulación acromioclavicular,
ligamento acromiocoracoideo y
apófisis coracoides (Neer 1983)!

38. Diagnóstico!

39. Exploración física!
SYSTEMATIC REVIEW
Diagnostic Accuracy of Clinical Tests for Subacromial
Impingement Syndrome: A Systematic Review and
Meta-Analysis
Marwan Alqunaee, RCSI, Rose Galvin, BSc (Physio), PhD, Tom Fahey, MD, FRCGP
ABSTRACT. Alqunaee M, Galvin R, Fahey T. Diagnostic
accuracy of clinical tests for subacromial impingement syn-
drome: a systematic review and meta-analysis. Arch Phys Med
Rehabil 2012;93:229-36.
Objective: To examine the accuracy of clinical tests for
diagnosing subacromial impingement syndrome (SIS).
Data Sources: A systematic literature search was conducted
in January 2011 to identify all studies that examined the diag-
nostic accuracy of clinical tests for SIS. The following search
engines were used: Cochrane Library, EMBASE, Science Di-
rect, and PubMed.
Study Selection: Two reviewers screened all articles. We
included prospective or retrospective cohort studies that exam-
ined individuals with a painful shoulder, reported any clinical
test for SIS, and used arthroscopy or open surgery as the
reference standard. The search strategy yielded 1338 articles of
which 1307 publications were excluded based on title/abstract.
Sixteen of the remaining 31 articles were included. The
PRISMA (preferred reporting items for systematic reviews and
meta-analyses) guidelines were followed to conduct this
review.
Data Extraction: The number of true positives, false posi-
tives, true negatives, and false negatives for each clinical test
were extracted from relevant studies, and a 2ϫ2 table was
constructed. Studies were combined using a bivariate random-
effects model. Heterogeneity was assessed using the variance
of logit-transformed sensitivity and specificity.
Data Synthesis: Ten studies with 1684 patients are included
in the meta-analysis. The Hawkins-Kennedy test, Neer’s sign,
and empty can test are shown to be more useful for ruling out
rather than ruling in SIS, with greater pooled sensitivity esti-
mates (range, .69–.78) than specificity (range, .57–.62). A
negative Neer’s sign reduces the probability of SIS from 45%
to 14%. The drop arm test and lift-off test have higher pooled
specificities (range, .92–.97) than sensitivities (range, .21–.42),
indicating that they are more useful for ruling in SIS if the test
is positive.
Conclusions: This systematic review quantifies the diagnostic
accuracy of 5 clinical tests for SIS, in particular the lift-off test.
Accurate diagnosis of SIS in clinical practice may serve to
improve appropriate treatment and management of individuals
with shoulder complaints.
Key Words: Meta-analysis; Rehabilitation; Sensitivity and
specificity; Subacromial impingement syndrome.
© 2012 by the American Congress of Rehabilitation
Medicine
SHOULDER PAIN IS the third most common musculosk-
eletal consultation in primary care, and second most com-
mon cause of referrals to orthopedic and sports medicine clin-
ics.
1,2 The differential diagnosis of conditions that cause
shoulder pain is a challenging and complex area of musculo-
skeletal practice. Subacromial impingement syndrome (SIS) is
the most frequent cause of shoulder pain. SIS is a clinical
syndrome that indicates pain and pathology relating to the
subacromial bursa and rotator cuff tendons within the subacro-
mial space. The 3 stages of SIS are subacromial bursitis,
partial-thickness and full-thickness rotator cuff tears.3
The
cause of SIS is considered to be multifactorial, with both
extrinsic and intrinsic factors involved in its pathogenesis.
4
The
primary factors relating to the intrinsic theory are muscle
overload and weakness, shoulder overuse and repetitive tissue
microtrauma, and degeneration of the rotator cuff. The key
elements of the extrinsic hypothesis are shape of the acromion,
glenohumeral instability, altered scapulothoracic rhythm, os
acromiale, and degeneration of the acromioclavicular joint.5,6
Clinicians have traditionally relied on a clinical examination
comprising a subjective history and physical examination, fol-
lowed by various clinical tests to diagnose SIS. Numerous
clinical tests have been described to evaluate the presence of
impingement syndrome and to determine the integrity of the
individual components of the rotator cuff.7
These tests can be
broadly classified as impingement or pain provocation tests and
rotator cuff strength tests. Impingement tests are designed to
reproduce symptoms or pain by compressing the greater tuber-
osity against the acromion.8,9
Rotator cuff strength tests assess
the integrity of the individual rotator cuff tendons and their
respective musculotendinous units. Table 1 contains the com-
From the HRB Centre for Primary Care Research, Department of General Practice,
Royal College of Surgeons in Ireland, Dublin, Republic of Ireland.
Supported by the Health Research Board (HRB) of Ireland through the HRB Centre
for Primary Care Research (grant no. HRC/2007/1).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organi-
zation with which the authors are associated.
Reprint requests to Rose Galvin, BSc (Physio), PhD, HRB Centre for Primary Care
Research, Dept of General Practice, Royal College of Surgeons in Ireland, 123 St.
Stephens Green, Dublin 2, Republic of Ireland, e-mail: rosegalvin@rcsi.ie.
0003-9993/12/9302-00341$36.00/0
doi:10.1016/j.apmr.2011.08.035
List of Abbreviations
CI confidence interval
LR likelihood ratio
PRISMA preferred reporting items for systematic
reviews and meta-analyses
QUADAS quality assessment of diagnostic
accuracy studies
ROC receiver operating characteristic
SIS subacromial impingement syndrome
229
Arch Phys Med Rehabil Vol 93, February 2012
Database of Abstracts of Reviews of Effects (DARE)
Produced by the Centre for Reviews and Dissemination
Copyright © 2014 University of York
Page: 1 / 3
Which physical examination tests provide
clinicians with the most value when examining
the shoulder? Update of a systematic review
with meta-analysis of individual tests. Hegedus
EJ, Goode AP, Cook CE, Michener L, Myer CA,
Myer DM, Wright AA. Database of Abstracts of
Reviews of Effects (DARE). 25 Abril 2013!
Diagnostic accuracy of clinical tests for!
subacromial impingement syndrome: a
systematic review and meta-analysis. Alqunaee
M, Galvin R, Fahey T. Arch!
Phys Med Rehabil. 2012 Feb;93(2):229-36. !
Physical tests for shoulder!
impingements and local lesions of bursa, tendon
or labrum that may accompany!
impingement. Hanchard NC, et al. Cochrane
Database Syst Rev. 2013 Apr 30;4:CD007427. !
Physical tests for shoulder impingements and local lesions of
bursa, tendon or labrum that may accompany impingement(Review)
Hanchard NCA, Lenza M, Handoll HHG, Takwoingi Y
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2013, Issue 4
http://www.thecochranelibrary.com
Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

40. Alto Valor
Predictivo
Negativo!
S. Subacromial!
Alta
Sensibilidad!
Hawkins-Kennedy !
Signo del Neer !
Empty-Can (Jobe)!

41. Alto Valor
Predictivo
Positivo!
Alta
Especificidad!
Drop Arm!
Lift off Test!

42. Desgarro de subescapular !
– Internal rotation lag sign: sensibilidad muy
alta 97 %!
– Lift-Off Test: alta especificidad!

43. Patología del Infraespinoso: !
– Patte: tenía una especificidad muy alta 95 %,
pero también de alta sensibilidad 94%!
– Rot externa contra resistencia: una
especificidad del 99% y la sensibilidad de 96% !

44. Patología del Supraespinoso: !
– No había ninguna prueba individual con
propiedades tan altas!
– Empty Can Test (Jobe) puede ser útil para
descartar la lesión con sensibilidad de 94%!

45. Diagnóstico por Imagen!
SENSIBILIDAD! ESPECIFICIDAD!
RMN! ECO! A-RM! RMN! ECO! A-RM!
ROTURAS
COMPLETAS!
0,94! 0,92! 0,94! 0,93! 0,93! 0,92!
Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NCA, Faloppa F. Magnetic
resonance imaging, magnetic resonance arthrography and ultrasonography for assessing
rotator cuff tears in people with shoulder pain for whom surgery is being considered.
Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD009020. DOI:
10.1002/14651858.CD009020.pub2.!
• No
hubo
diferencia
estadís4camente
significa4va
en
el
rendimiento
de
diagnós4co
para
la
detección
de
desgarros
de
espesor
completo
al
comparar
la
RM,
ecograaa
y
artroRM.

46. SENSIBILIDAD! ESPECIFICIDAD!
RMN! ECO! A-RM! RMN! ECO! A-RM!
ROTURAS
PARCIALES!
0,74! 0,52! *! 0,93! 0,93! *!
Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NCA, Faloppa F. Magnetic
resonance imaging, magnetic resonance arthrography and ultrasonography for assessing
rotator cuff tears in people with shoulder pain for whom surgery is being considered.
Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD009020. DOI:
10.1002/14651858.CD009020.pub2.!
• El
rendimiento
diagnós4co
de
la
resonancia
magné4ca
y
de
la
ecograaa
puede
ser
similar,
pero
disminuye
su
sensibilidad
para
la
detección
de
desgarros
de
espesor
parcial.
*
No
posible
metaanálisis
Diagnóstico por Imagen!

47. Ramon P. Ottenheijm, Mariëtte J. Jansen, J. Bart Staal, Ann van den Bruel, René E.
Weijers, Rob A. de Bie, Geert-Jan Dinant, Accuracy of Diagnostic Ultrasound in Patients
With Suspected Subacromial Disorders: A Systematic Review and Meta-Analysis . Arch
Phys Med Rehabil Vol 91, October 2010!
SENSIBILIDAD! ESPECIFICIDAD!
BURSITIS
SUBACROMIAL!
0,79-0,81! 0.94 - 0 .98!
TENDINOPATÍAS! 0,67-0,93! 0.88 - 1.00!
T. CALCIFICANTE! 1! 0.85 - 0.98!
Diagnóstico por Imagen!

48. Tratamiento!

49. REVIEW ARTICLE (META-ANALYSIS)
Subacromial Impingement Syndrome: Effectiveness
of Pharmaceutical InterventionseNonsteroidal
Anti-Inflammatory Drugs, Corticosteroid, or Other
Injections: A Systematic Review
Renske van der Sande, MD,a
Willem D. Rinkel, MSc,b
Lukas Gebremariam, MD,a
Elaine M. Hay, FRCP, MD,c
Bart W. Koes, PhD,a
Bionka M. Huisstede, PhDa,b
From the Departments of a
General Practice and b
Rehabilitation Medicine, Erasmus MC e University Medical Center, Rotterdam, The
Netherlands; and c
the Arthritis Research Campaign National Primary Care Centre, Keele University, Keele, United Kingdom.
Abstract
Objective: To present an evidence-based overview of the effectiveness of pharmaceutical interventions, including nonsteroidal anti-inflammatory
drugs, corticosteroid injections, and other injections, used to treat the subacromial impingement syndrome (SIS). An overview can help physicians
select the most appropriate pharmaceutical intervention, and it can identify gaps in scientific knowledge.
Data Sources: The Cochrane Library, PubMed, Embase, PEDro, and CINAHL databases.
Study Selection: Two reviewers independently selected relevant reviews and randomized clinical trials.
Data Extraction: Two reviewers independently extracted the data and assessed the methodologic quality.
Data Synthesis: A best evidence synthesis was used to summarize the results. Three reviews and 5 randomized clinical trials were included.
Although we found limited evidence for effectiveness in favor of 2 sessions with corticosteroid injections versus 1 session, for the effectiveness of
corticosteroid injections versus placebo, nonsteroidal anti-inflammatory drugs, or acupuncture, only conflicting and no evidence for effectiveness
was found. Moderate evidence was found in favor of immediate release oral ibuprofen compared with sustained-released ibuprofen in the short-
term. Also, moderate evidence for effectiveness was found in favor of glyceryltrinitrate patches versus placebo patches in the short-term and mid
term. Furthermore, injections with disodium ethylene diamine tetraacetic acid plus ultrasound with ethylene diamine tetraacetic acid gel were
more effective (moderate evidence) than was placebo treatment in the short- and long-term.
Conclusions: This article presents an overview of the effectiveness of pharmaceutical interventions for SIS. Some treatments seem to be
promising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn.
Archives of Physical Medicine and Rehabilitation 2013;94:961-76
ª 2013 by the American Congress of Rehabilitation Medicine
Musculoskeletal disorders of the shoulder, including tendinitis
and bursitis, are difficult to differentiate in clinical practice. In
the Complaints of the Arm, Neck, and/or Shoulder (CANS) model,
the term subacromial impingement syndrome (SIS) is used for the
rotator cuff syndrome, tendonosis of the Musculus infraspinatus,
Musculus supraspinatus, and Musculus subscapularis, and bursitis
in the shoulder area.1
More than 50% of the patients suffering from
chronic CANS reported complaints of the shoulder.2
The relation
between shoulder complaints and work-related factors, such as
repetitive work, working with the hand above the shoulder, and high
psychosocial job demands, has been found positive by
several authors.3
In general practice, SIS is the most frequently reported diag-
nosis of the shoulder, with a cumulative incidence of 5 per 1000
patients per year.4
Patients with SIS are characterized by pain
localized in the shoulder that is exacerbated when performing
overhead activities.5
The first step in treatment for SIS by
a general practitioner often includes an analgesic.6
Also, corti-
costeroid injections are an often-used intervention in primary
care.7
New treatment modalities such as tenoxicam injections8
No commercial party having a direct financial interest in the results of the research supporting
this article has or will confer a benefit on the authors or on any organization with which the authors
are associated.
0003-9993/13/$36 - see front matter ª 2013 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2012.11.041
Archives of Physical Medicine and Rehabilitation
journal homepage: www.archives-pmr.org
Archives of Physical Medicine and Rehabilitation 2013;94:961-76
Subacromial Impingement Syndrome:
Effectiveness of Pharmaceutical
Interventions–Nonsteroidal Anti-
Inflammatory Drugs, Corticosteroid, or
Other Injections: A Systematic Review!
Renske van der Sande, et al. Archives of
physical medicine and rehabilitation 1 May
2013!

50. AINES!
Múl4ples
ECA:
• Diclofenaco
• Flurbiprofeno
• Naproxeno
• Celecoxib
• Ibuprofeno
• Ibupfofeno
liberación
sostenida
Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti-
Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review!
Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013!
Celecoxib único que compara
con placebo!
II!

51. AINES!
Múl4ples
ECA:
• Diclofenaco
• Flurbiprofeno
• Naproxeno
• Celecoxib
• Ibuprofeno
• Ibupfofeno
liberación
sostenida
Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti-
Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review!
Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013!
Celecoxib único que compara
con placebo!
PENDIENTES
ACTUALIZACIÓN
DE
LA
COCHRANE
II!

52. Otros fármacos orales!
• No disponemos de ensayos clínicos
aleatorizados sobre AINEs tópicos, Paracetamol
y Opioides!
• Guías Práctica clínica: Recomendado el control
del dolor con analgésicos.!
III!

53. Parches de nitroglicerina!
Estudio basado en 1 ECA!
• Parche NTG + RHB!
• Placebo + RHB!
• Hay débil evidencia de la efectividad
de los parches de nitroglicerina Vs
placebo a corto (12 semanas) y
medio plazo (24 semanas)!
• Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti-Inflammatory
Drugs, Corticosteroid, or Other Injections: A Systematic Review Renske van der Sande, et al. Archives of physical
medicine and rehabilitation 1 May 2013 (volume 94 issue 5 Pages 961-976 DOI: 10.1016/j.apmr.2012.11.041)!
III!

54. Infiltraciones esteroides
Patología del manguito!
• 5 ECAS !
• Mejoría significativa del dolor Vs placebo!
• No diferencias al comparar con TENS u Onda
corta!
• Rabini A, et al Effects of local microwave diathermy on shoulder pain and function in patients with rotator
cuff tendinopathy in comparison to subacromial corticosteroid injections: a single-blind randomized trial. J
Orthop Sports Phys Ther. 2012 Apr;42(4):363-70. doi: 10.2519/jospt.2012.378722281781. Epub 2012 Jan
25. !
• Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti-
Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review. Renske van der Sande, et
al. Archives of physical medicine and rehabilitation 1 May 2013. !
II!

55. Infiltraciones esteroides
S. Subacromial!
• 7 ECAS (4 alta calidad) = empate a 2.!
• Evidencia conflictiva sobre la efectividad de las
inyecciones con corticoides Vs placebo a corto
(4 semanas) y medio plazo (12 semanas)!
Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti-
Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review!
Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013!
D!

56. Infiltraciones AINES
S. Subacromial!
• 3 ECAS.!
• No diferencias significativas en la infiltración con
corticoide Vs AINE. !
• No diferencias entre infiltración combinada
corticoide + AINE!
!
Subacromial Impingement Syndrome: Effectiveness of Pharmaceutical Interventions–Nonsteroidal Anti-
Inflammatory Drugs, Corticosteroid, or Other Injections: A Systematic Review!
Renske van der Sande, et al. Archives of physical medicine and rehabilitation 1 May 2013!
II!

57. ¿Infiltraciones ecoguiadas?!
Bloom JE, Rischin A, Johnston RV, Buchbinder R. Image-guided versus blind
glucocorticoid injection for shoulder pain. Cochrane Database of Systematic
Reviews 2012, Issue 8. Art. No.: CD009147. DOI:
10.1002/14651858.CD009147.pub2.!
II!
• Pruebas de calidad moderada indican que
no hay ninguna diferencia en el dolor o la
función !
• Pruebas de calidad moderada sugiere que
hay probablemente ninguna diferencia en
la incidencia de eventos adversos!

58. Plasma rico en plaquetas!
No evidencia del
beneficio del PRP en
patología del manguito.!
II!
Arthroscopy. 2012 Nov;28(11):1718-27. doi: 10.1016/j.arthro.
2012.03.007. Epub 2012 Jun 12.!
The role of platelet-rich plasma in arthroscopic rotator cuff
repair: a systematic review with quantitative synthesis.!
Chahal J, Van Thiel GS, Mall N, Heard W, Bach BR, Cole BJ,
Nicholson GP, Verma NN, Whelan DB, Romeo AA.!
Cochrane Database Syst Rev. 2013 Dec 23;12:CD010071.
doi: 10.1002/14651858.CD010071.pub2.!
Platelet-rich therapies for musculoskeletal soft tissue
injuries.!
Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC.!

59. Laser!
• Yavuz F, Duman I, Taskaynatan MA, Tan AK. Low-level laser therapy versus ultrasound therapy in the treatment of subacromial
impingement syndrome: A Rndomized clinical trial. J Back Musculoskelet Rehabil. 2013 Dec 17. [Epub ahead of print]
PubMed PMID: 24346151!
• Eslamian F, Shakouri SK, Ghojazadeh M, Nobari OE, Eftekharsadat B. Effects of low-level laser therapy in combination with
physiotherapy in the management of rotator cuff tendinitis. Lasers Med Sci. 2012 Sep;27(5):951-8. doi:
10.1007/10103-011-1001-3!
• Tendinopatía del manguito:
Mejora el dolor a corto plazo
Vs placebo y Ultrasonido.!
• S. Subacromial: evidencia
conflictiva!
II!

60. Magnetoterapia!
• Tendinopatía cálcica y SIS a
corto y medio plazo!
• Significificación clínica débil!
• 1ECA No efecto en otros
procesos!
Pulsed electromagnetic field and exercises in patients with shoulder impingement syndrome: a randomized,
double-blind, placebo-controlled clinical trial. Galace de Freitas D, Marcondes FB, Monteiro RL, Rosa SG, Maria
de Moraes Barros Fucs P, Fukuda TY. Arch Phys Med Rehabil. 2014 Feb;95(2):345-52.!
II!

61. Ultrasonidos!
• Evidencia conflictiva de los
US Vs placebo a corto plazo. !
• No evidencia a medio plazo.!
Subacromial impingement syndrome—effectiveness of physiotherapy and
manual therapy. Lukas Gebremariam, et al. Br J Sports Med 2013;0:1–8. doi:
10.1136/bjsports-2012-091802 !
!
D!

62. Iontoforesis ac.
acético!
Evidencia moderada de
NO eficacia en la
reabsorción de calcio.!
II!
Ciccone CD. Does acetic acid iontophoresis accelerate the resorption of calcium
deposits in calcific tendinitis of the shoulder? Phys Ther. 2003 Jan;83(1):68-74.
PubMed PMID: 12495407.!

63. Ondas de choque!
• Tendinopatía
calcificante: Son mas
efectivas que placebo
para mejorar el dolor, la
calcificación y la función. !
• Tendinopatía no
calcificante: no son
eficaces !
Clinical improvement and resorption of calcifications in calcific tendinitis of the shoulder after shock wave
therapy at 6 months' follow-up: a systematic review and meta-analysis.!
Ioppolo F, Tattoli M, Di Sante L, Venditto T, Tognolo L, Delicata M, Rizzo RS, Di Tanna G, Santilli V.!
Arch Phys Med Rehabil. 2013 Sep;94(9):1699-706. doi: 10.1016/j.apmr.2013.01.030. Epub 2013 Mar 13.!
!
I!

64. Kinesio tape!
Actualmente no existe
evidencia para apoyar el
uso de kionesio tape en la
práctica clínica.!
Physiother Theory Pract. 2013 May;29(4):259-70. doi:
10.3109/09593985.2012.731675. Epub 2012 Oct 22.!
The clinical effects of Kinesio® Tex taping: A systematic review.!
Morris D, Jones D, Ryan H, Ryan CG.!
II!

65. Ejercicio!
• Hasta 19 ECA analizados!
• Es necesario estandarizar y
describir los protocolos de
tratamiento.!
• Son necesarios estudios de mayor
calidad metodológica.!
II!
The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic
review and meta-analysis.!
Hanratty CE, et al. Database of Abstracts of Reviews of Effects (DARE) Septiembre 2013!
!

66. Ejercicio!
• Reduce el dolor!
• Aumenta la Fuerza.!
• Mejora la Función (autopercibida)!
• Mejora la Calidad de Vida !
• Los ejercicios domiciliarios son tan
efectivos como los supervisados
por fisioterapeutas !
II!
The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic
review and meta-analysis.!
Hanratty CE, et al. Database of Abstracts of Reviews of Effects (DARE) Septiembre 2013!
!

67. Radiofrecuencia!
• 4 ECA !
• Mejoría significativa del dolor!
• Resultados se mantienen a medio
plazo!
II!

68. Cirugía!
No diferencias en los resultados
en el dolor y la función del
hombro entre la actitud
conservadora y quirúrgica!
Clin J Sport Med. 2013 Sep;23(5):406-7. doi: 10.1097/01.jsm.0000433152.74183.53.!
Is there evidence in favor of surgical interventions for the subacromial impingement syndrome?!
Tashjian RZ.!
I!

69. Cirugía!
• No diferencias entre Cirugia
abierta, artroscópica o “mini-
open”!
• No diferencias entre fijación
“single-row” o “double-row”.!
Clin J Sport Med. 2013 Sep;23(5):406-7. doi:
10.1097/01.jsm.0000433152.74183.53.!
Is there evidence in favor of surgical interventions for the
subacromial impingement syndrome?!
Tashjian RZ.!
II!
Seida J, et al. Comparative Effectiveness of Nonoperative and
Operative Treatment for Rotator Cuff Tears. Comparative Effectiveness
Review No. 22. (Prepared by the University of Alberta Evidence-based
Practice Center) AHRQ 2010.!

70. Descompresión subacromial!
Programa Individual!
Ejercicio! Terapia manual!
Programa Grupal!
Ejercicio terapéutico!
AINES +/- ANALGÉSICOS!
+ Programa domiciliario!
Intervencionismo!
Radiofrecuencia! Artroscopia!
Tto individual!
Ondas de choque! Magnetoterapia ?!
Infiltración + Ejercicio Terapéutico!
AINES +/ LASER!
+ Programa domiciliario!
Propuesta tratamiento!
S. Subacromial puro! Tendinopatía (incluida cálcica)!

71. INESTABILIDAD!

72. La luxación de hombro representa casi
el 50% de todas las luxaciones
articulares. !
!
Son anteriores en 90-98% de los
casos!
• Inestabilidad de hombro. Scott Welsh et al. Actualización Medscape Septiembre 2012!
• Consensus statement on shoulder instability. Arthroscopy. 2010 Feb;26(2):249-55. Bak K, Wiesler
ER, Poehling GG; ISAKOS Upper Extremity Committee.!

73. Diagnóstico!

74. Exploración física!
Database of Abstracts of Reviews of Effects (DARE)
Produced by the Centre for Reviews and Dissemination
Copyright © 2014 University of York
Page: 1 / 3
Which
physical
examina4on
tests
provide
clinicians
with
the
most
value
when
examining
the
shoulder?
Update
of
a
systema4c
review
with
meta-­‐analysis
of
individual
tests.
Hegedus
EJ,
Goode
AP,
Cook
CE,
Michener
L,
Myer
CA,
Myer
DM,
Wright
AA.
Database
of
Abstracts
of
Reviews
of
Effects
(DARE).
25
Abril
2013
Physical tests for shoulder!
impingements and local lesions of bursa,
tendon or labrum that may accompany!
impingement. Hanchard NC, et al.
Cochrane Database Syst Rev. 2013 Apr
30;4:CD007427. !
Physical tests for shoulder impingements and local lesions of
bursa, tendon or labrum that may accompany impingement(Review)
Hanchard NCA, Lenza M, Handoll HHG, Takwoingi Y
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2013, Issue 4
http://www.thecochranelibrary.com
Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

75. Lesiones del Labrum (sup): Test de
compresión pasiva con una sensibilidad
del 89%, especificidad 85%!

76. Inestabilidad anterior: Test de aprehesión
con una sensibilidad del 65%, especificidad
95%!

77. Inestabilidad anterior:
Test de la sorpresa
con una sensibilidad del
81%, especificidad 86%!

78. Diagnóstico por Imagen!
Diagnostic Value of US, MR y MR artrography in shoulder inestability. Roman
Pavic et al. Injury Int J. Care (2013) S26-S32!
La RM es la prueba de elección inicial, con
una especificidad del 82% y sensibilidad del
94%!
!
La artro-RM es el gold standard para la
evaluación previa a la cirugía.!

79. Diagnóstico por Imagen!
La RM es más precisa para lesiones de Hill-
Sachs o Bankart!
!
La artro-RM es superior en lesiones
ligamentosas complejas y del labrum!
Diagnostic Value of US, MR y MR artrography in shoulder inestability. Roman
Pavic et al. Injury Int J. Care (2013) S26-S32!

80. Tipo de
Inmovilización!
No diferencias entre la inmovilización en rotación
externa Vs rotación interna!
Immobilization in internal or external rotation does not change recurrence rates after traumatic
anterior shoulder Dislocation. Patrick Vavken, et al. J Shoulder Elbow Surg (2014) 23, 13-19!
mulative RR for recurrent dislocations after immobilization in internal rotation (IR) and external rotation (ER) for patients
r younger. The pooled estimates are very similar to those for all ages, mostly because a large majority of patients with
tions are adolescents and young adults.
P. Vavken et al.
final analysis of recurrent dislocation. However, we did find
high values for post hoc power analysis.
Conclusion
The currently available best evidence does not support
a relative effectiveness of immobilization in external
rotation compared with internal rotation in reducing
recurrent shoulder dislocations in patients with traumatic
anterior shoulder dislocations. However, after we
reviewed the current clinical data and the ava
science, it is our opinion that a yet-to-be-
subgroup of patients could benefit from such
Future investigations are needed to test this
Disclaimer
The authors, their immediate families, and a
foundations with which they are affiliate
Figure 4 Cumulative RR for recurrent dislocations after immobilization in internal rotation (IR) and external rotation (E
aged older than 30 years.
Figure 3 Cumulative RR for recurrent dislocations after immobilization in internal rotation (IR) and external rotation (E
aged 30 years or younger. The pooled estimates are very similar to those for all ages, mostly because a large majority o
shoulder dislocations are adolescents and young adults.
II!Tratamiento conservador!

81. Tiempo de
Inmovilización!
Edad < 13 años es un factor predictivo de
recurrencia!
!
No hay beneficios en inmovilizar > 1 semana
en pacientes jóvenes!
!
Immobilization in internal or external rotation does not change recurrence rates after traumatic
anterior shoulder Dislocation. Patrick Vavken, et al. J Shoulder Elbow Surg (2014) 23, 13-19!
II!

82. Programa de
Rehabilitación!
Consensus statement on shoulder instability. Arthroscopy. 2010 Feb;26(2):249-55. !
Bak K, Wiesler ER, Poehling GG; ISAKOS Upper Extremity Committee.!
• Diseño individualizado!
• Programa de ejercicios!
• Recuperación del rango de
movimiento!
• Ejercicios dinámicos!
• Propioceptivos!
• Estabilización escapular!
III!

83. Ejercicios
Isocinéticos!
Los programas Isocinéticos son
eficaces en la evaluación y
rehabilitación de la inestabilidad de
hombro microtraumatica!
Isokinetic intervention in microtraumatic shoulder instability: an update. Gremeaux V, Croisier JL,
Forthomme B. J Sports Med Phys Fitness. 2012 Aug;52(4):413-23. Review. PubMed PMID: 22828467.!
II!

84. Cirugia!
Chahal J, Marks PH, Macdonald PB, Shah PS, Theodoropoulos
J, Ravi B, Whelan DB. Anatomic Bankart repair!
compared with nonoperative treatment and/or arthroscopic
lavage for first-time traumatic shoulder dislocation.!
Arthroscopy 2012; 28(4): 565-575!
II!
La reparación
artroscópica reduce la
inestabilidad recurrente y
mejora la calidad de vida
en adultos jóvenes tras la
primera luxación.!