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he effectiveness of digital infrared thermographic imagingn patients with shoulder impingement syndrome

in-Young Park, MD,a Jung Keun Hyun, MD,b and Joong-Bae Seo, MD,c Seoul and Cheonan, Korea

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e prospectively evaluated 100 patients with unilat-ral impingement syndrome, before they underwent anrthroscopic subacromial decompression, to detect theelationship between clinical and operative findingsnd digital infrared thermographic imaging (DITI) find-

ngs in patients with shoulder impingement syndrome.he DITI system was used to measure the temperaturef each patient’s upper body, and the relative temper-ture values between involved and the uninvolvedides were used for analysis. A control group of 30ubjects without impingement syndrome was also eval-ated. In DITI findings, 73% of patients had abnormalhermal changes in more than 1 of the 4 regions ofnterest: 51% displayed hypothermia, and 22% hadyperthermia. In the hypothermic group, limitation ofhoulder motion was more prominent than in the hy-erthermic and normal groups (P � .05). Other clini-al findings did not correlate with the DITI findings,owever. DITI can be used to reflect shoulder stiffnessbjectively in impingement syndrome, especially in thoseases with a hypothermic thermal pattern. (J Shoulderlbow Surg 2007;16:548-554.)

houlder impingement syndrome is one of severalhoulder lesions commonly seen in the clinical settingnd is affected by pathologic contact between theotator cuff and the overlying coracoacromial arch.15

n many patients with shoulder impingement syn-rome, pain around the shoulder and in shoulderange of motion interferes with daily activities. Manylinical tests and radiologic methods have been de-cribed for evaluating impingement syndrome aftereer16 first described the syndrome in 1972. The

rom the aDepartment of Orthopaedic Surgery, Konkuk UniversitySchool of Medicine, and the bDepartments of RehabilitationMedicine, and cOrthopaedic Surgery, Dankook University Col-lege of Medicine.

eprint requests: J. K. Hyun, MD, Department of RehabilitationMedicine, Dankook University College of Medicine, San 16-5Anseo-dong, Cheonan, Chungnam, Korea (E-mail: rhhyun@dankook.ac.kr).opyright © 2007 by Journal of Shoulder and Elbow SurgeryBoard of Trustees.

058-2746/2007/$32.00

aoi:10.1016/j.jse.2006.11.010

48

ffectiveness of these tools varies, however, and theyre not adequate to reflect subjective symptoms suchs pain and stiffness.4,5,10,18

Thermography uses an infrared camera to cap-ure body surface heat. One of earliest clinical usesf thermography was to assist in breast canceriagnosis.6 Later, thermography became an impor-

ant adjunctive diagnostic tool in the assessment ofascular disease, autonomic nervous system dys-unction, peripheral neuropathy, and radiculopathyith disc herniation.1,2,21 Because of growing con-erns about pain, thermography has been used inhe diagnosis of myofascial pain.14 Some investi-ators have reported that thermography can besed to treat patients with temporomandibular painnd motion limitation.3,11

The purpose of this study was to evaluate patientsith shoulder impingement syndrome using digital

nfrared thermographic imaging (DITI) for the objec-ive detection of shoulder pain and limitation and alsoo reveal any other relationships among clinical, phys-cal, or operative findings and DITI.

ATERIALS AND METHODS

atientsWe selected patients from our shoulder and elbow joint

linic in the Department of Orthopaedic Surgery who hadomplaints of shoulder pain and were prospectively diag-osed with shoulder impingement syndrome. All subjectsere thought to have more than a moderate grade ofnilateral shoulder impingement syndrome from their his-ory, symptoms, signs, or radiologic findings. The diagnosisf subacromial impingement was confirmed though arthro-copic subacromial decompression. Patients were excludedrom the study if they exhibited bilateral impingement syn-rome, concomitant fractures in the upper extremities, in-ammatory skin lesions, peripheral neuropathy, plexopa-hy, or cervical radiculopathy, a condition that could affectkin temperature. The 100 selected patients (55 men, 45omen) were a mean of 52.0 � 11.2 years. The duration

rom onset of symptoms until operation was 22.6 � 40.4onths (Table I). Thirty adults served as normal controls for

he DITI study. Adults who had any shoulder lesions,rauma, fractures or pain, skin lesions, peripheral neuropa-hy, plexopathy, or cervical radiculopathy were excluded

s controls.

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J Shoulder Elbow Surg Park, Hyun, and Seo 549Volume 16, Number 5

istory, clinical symptoms, and physical examinationWe investigated trauma histories and clinical symptoms,

ncluding pain severity, using the Visual Analog ScaleVAS). Physical examination parameters included impinge-ent signs, tenderness around the shoulder joint, and rangef motion in the shoulder.

Three impingement tests were performed: Neer impinge-ent sign, the Hawkins impingement sign, and the coracoid

mpingement sign. Tenderness around the shoulder wasvaluated specifically on the supraspinatus tendon andreater tuberosity, the acromioclavicular joint, and the longead of the biceps tendon. The active range of shoulderotion was assessed in 6 directions: forward elevation,xternal rotation, external rotation at 90° of abduction,ross-body adduction, lateral rotation, and internal rota-ion. For statistical purposes, the results of the lateral andnternal rotations were converted into numbers. For lateralotation, the ear level was converted to 1, C1 to 2, C2 to 3,nd T1 to 9; for internal rotation, S1 was converted to 1, L5

o 2, L4 to 3, and T12 to 7.

perative findingsDuring surgery, subacromial impingement of the rotator

uff was confirmed in all subjects. The operations wereerformed using arthroscopic subacromial decompressionor treatment of the syndrome. The existence and grade ofotator cuff tears, bursitis, and synovitis were also identifiedt the time of surgery.

igital infrared thermographic imagingAll patients underwent DITI before surgery, and the 30

ontrol subjects only underwent DITI evaluation. The DITIevice used was an IRIS 5000 (Medicore, Seoul, Korea),hich consisted of an infrared camera, a computer, and a

iquid crystal display monitor. The device detected emitted

able I Subjects’ general characteristics

Characteristic Patients (n)

Age (years)10-19 120-29 030-39 940-49 3650-59 2860-69 2070-79 6

SexMale 55Female 45

Duration (months)0-6 416-12 2112-24 15�24 23

Total 100

nfrared energy from the body’s surface and then divided a

hermal differences into 16 color levels, using pixels. Thisnformation was displayed on a monitor.

The temperature within the DITI room was kept at aonstant range from 19 to 21°C, and the patients waitedith no clothing on their upper bodies for 15 minutes before

he start of the DITI. DITI was performed on the upper bodyn 4 views: anterior, posterior, and right and left lateraliews. The DITI results were analyzed by evaluating theocalized temperature difference around the shoulder andy the thermal patterns extending from the shoulder to theand.

Localized temperatures around the shoulder were as-essed by comparing the mean temperatures in 5 regions ofnterest (ROI): the anteromedial (AM), anterolateral (AL),ateral (LAT), posteromedial (PM), and posterolateral (PL)egions. The temperature differences in the 5 ROIs from thenvolved and uninvolved sides (�T) were calculated in pa-ients, and the 5 ROIs from both sides were calculated inontrol subjects (Figure 1). Abnormal temperature was de-ermined as the �T greater than the upper limit of absolutealue on 5 ROIs. The case was considered to be abnormalf at least 1 of the meaningful areas had an abnormalemperature after �2 analysis of the five ROIs.

The abnormal cases were divided into hyperthermic andypothermic groups. The hyperthermic group consisted ofases in which the temperature of the involved side wasigher than the uninvolved side. The hypothermic grouponsisted of the cases where the temperature of the involvedide was lower than the uninvolved side.

Thermal patterns extending from the shoulder to theand were graded from 0 to 4 (Figure 2). Grade 0 wasefined as no difference between the involved and theninvolved sides (Figure 2, A). Grade 1 was an abnormalhermal pattern seen in the shoulder only (Figure 2, B).rade 2 was an abnormal thermal pattern seen in the areaxtending from the shoulder to the upper arm (Figure 2, C).rade 3 represented an abnormal thermal pattern occur-

ing from the shoulder to the forearm (Figure 2, D). Gradewas an abnormal thermal pattern reaching from the

houlder to the hand (Figure 2, E). Cases that had abnormalhermal patterns on the shoulder and forearm or hand, butere not continuous from the shoulder, were considered toe grade 1. Cases with abnormal thermal patterns on thepper arm, forearm, or hand, without a continuation fromhe shoulder, were considered to be grade 0. When casesad a localized temperature around the shoulder, the ab-ormal cases (grade 1 or more) were divided into hyper-hermic and hypothermic groups.

ata analysisStatistical analysis was performed using SPSS 13.0

SPSS Inc, Chicago, IL). An independent t test was per-ormed for the comparison of each ROI in the patients andontrol subjects. To compare clinical symptoms, physicalxamination findings, and the operative findings from the 3atient groups, a 1-way analysis of variance with a Bonfer-oni post hoc test was performed for the numeric data, and

Pearson �2 analysis was done for the binomial data.hermal patterns with grading and clinical symptoms, phys-cal examinations, and operative findings were also com-ared with a 1-way analysis of variance and a Pearson �2

nalysis. A Pearson linear correlation was performed to

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550 Park, Hyun, and Seo J Shoulder Elbow SurgSeptember/October 2007

elineate the correlation between the clinical and the ther-ographic data. Significance was determined at P � .05.ontinuous data are presented as the mean � standardeviation.

ESULTSistory, clinical symptoms, and physical examination

The incidence of patients with a history of shoulderrauma was 38%. All patients who had shoulder painefore surgery had a mean VAS score of 6.6 � 0.8range, 5.5-9). Physical examination revealed that 82atients (82%) had a positive impingement sign, and

Figure 1 Five regions of interest around the shouldbetween the involved and uninvolved sides were calculaside) � AM2 (uninvolved side); anterolateral regioposteromedial region (PM) � PM1 (involved side) �(involved side) � PL2 (uninvolved side); lateral region

8 (68%) had tenderness of the supraspinatus and c

reater tuberosity. All ranges of motion were limitednly in the involved shoulder (P � .05). During theperation, most of the subjects had bursitis (79%) andynovitis (84%). Rotator cuff tears were seen in 58atients (58%; Table II).

igital infrared thermographic imaging findings

The temperature differences (�T) between involvednd uninvolved shoulders in all 5 ROIs of the patientsere different from the �T of both shoulders of theontrol group (Table III). The maximal and minimalalues within the control group were more optimal

ere detected by thermography. Regional differencess follows: anteromedial region (AM) � AM1 (involved) � AL1 (involved side) � AL2 (uninvolved side);(uninvolved side); posterolateral region (PL) � PL1� L1 (involved side) � L2 (uninvolved side).

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J Shoulder Elbow Surg Park, Hyun, and Seo 551Volume 16, Number 5

erences than the summation and subtraction of theverage and 2 standard deviations of each ROI,ccording to the calculation of sensitivity and speci-city under the ROC curve. The cutoff points of eachOI were AM region, �0.36°C; AL, �0.47°C; PM,0.52°C; PL, �0.38°C; and LAT, �0.50°C.After setting the cutoff points, Pearson �2 analysis

igure 2 Grading of the pattern and extent of temperaturehanges compared with both upper extremities. A, Grade 0: noifference was found between the involved and the uninvolvedides. B, Grade 1: side-to-side temperature difference was seen inhe shoulder only. C, Grade 2: temperature difference seen fromhe shoulder to the upper arm. D, Grade 3: temperature differenceeen from the shoulder to the forearm. E, Grade 4: temperatureifference seen from the shoulder to the hand.

as performed on 5 ROIs in the control and patient w

roups, and the PM region of the patient group wasot statistically different from the control group (P �05). Therefore, if at least 1 of the 4 ROIs (AM, AL, PLnd LAT regions) had an abnormal temperature, thease was considered to be abnormal.

The normal group contained 27 subjects (27%).he abnormal group consisted of the remaining 73atients (73%): 51 (51%) were in the hypothermicroup and 22 (22%) were in the hyperthermic group.

Graded on a scale of 0 to 4, the results of thehermal patterns extending from shoulder to hand

able II Subjects’ clinical symptoms, physical findings, andperative findings

Clinical findings No. or mean � SD

rauma history 39ain score (VAS) 6.6 � 0.8mpingement signs

Neer impingement 82Hawkin’s impingement 71Coracoid impingement 14

ocal tendernessSS/GTT tenderness

I 7II 17III 44

Total 68AC3 tenderness

I 4II 8III 5

Total 17LHB tenderness

I 12II 12III 5

Total 29ange of motionForward elevation 27.1° � 30.3°External rotation 54.7° � 24.9°ER90 68.2° � 19.3°Cross-body adduction 25.7° � 5.0°Lateral rotation* 8.8 � 3.0Internal rotation* 8.6 � 3.9perative findingsRotator cuff tear

Partial 53Complete 5

Bursitis 79Synovitis 84

otal 100

D, Standard deviation; VAS, Visual Analog Scale; SS/GTT, supraspinatusnd greater tuberosity; AC, acromioclavicular joint; LHB, long head oficeps brachii; ER90, external rotation at a 90° abduction.For lateral rotation, the ear level was converted to 1, C1 to 2, C2 to 3, and1 to 9; for internal rotation, S1 was converted to 1, L5 to 2, L4 to 3, and T12o 7.

ere grade 0 in 40 patients (40%), grade 1 in 15

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15%), grade 2 in 16 (16%), grade 3 in 16 (16%),nd grade 4 in 13 patients (13%).

omparison between history, clinical symptoms,hysical examination results, and digital infrared

hermographic imaging findings

Table IV shows the comparison of clinical symp-oms and physical and operative findings among the

groups. Trauma history, age, gender, duration,ain, and tenderness were similar among the 3roups (P � .05). Forward elevation and externalotation were more reduced in the hypothermic group118.6° � 30.8° and 47.8° � 26.1°, respectively)han in the hyperthermic (133.6° � 25.9° and1.2° � 19.2°, respectively) and normal (136.9° �9.4° and 61.2° � 24.4°, respectively) groups (P �05). In the operative findings, the incidence amonghe 3 groups for rotator cuff tears, bursitis, and syno-itis was similar (P � .05).

The correlations between meaningful range of mo-ion and the results from the 5 ROIs of the hypothermicroup are summarized in Table V. The range oforward elevation had a positive linear correlationith the LAT ROI (P � .05), and the range of external

otation had a positive linear correlation with the ALnd PL ROIs (P � .05).

ISCUSSION

Accurate diagnosis of shoulder impingement syn-rome is essential when surgical management is con-idered.15 Diagnostic detection methods can be clas-ified into clinical and radiological diagnosis.

Clinical diagnosis with physical examinations issed widely for the detection of shoulder lesions,ncluding impingement syndrome. Some studies, how-ver, have indicated that the impingement sign isnsufficient to diagnose impingement syndrome. Thisnadequacy is due to 3 factors: poor accuracy,10 thelinical examination can rule out the presence of aotator cuff tear only if done by a clinical specialist

able III Results of digital infrared thermographic imagingemperature difference for the 5 regions of interest

Regions Patients* Controls* P

nteromedial �0.176 � 0.277† �0.002 � 0.157 .004nterolateral �0.412 � 0.340† 0.045 � 0.196 .001osteromedial �0.418 � 0.476† 0.018 � 0.196 .013osterolateral �0.234 � 0.259† �0.047 � 0.152 .030ateral �0.291 � 0.450† 0.031 � 0.168 .039

Values are expressed as mean � standard deviation in °C.P � .05 compared with control group by independent t test.

uch as an orthopedic surgeon, and no conclusive c

vidence favors any single test to detect rotator cuffisorders accurately.5

Radiologic tests are also used to assess impinge-ent syndrome. These include simple radiography,rthrography, ultrasound, magnetic resonance imag-

ng, and magnetic resonance arthrography. Both clin-cal assessment and radiologic tests can detect full-hickness rotator cuff tears relatively well, but they areot accurate in evaluating other soft-tissue disordershat are attributed to 90% of shoulder pain.14

Thermography is rarely used for the assessment ofhoulder disorders, although some investigators havetudied adhesive capsulitis in the past.13,19 Jeraci-ano et al13 found that patients with adhesive capsu-itis displayed an abnormal temperature response.hey concluded that these abnormalities clearly sug-ested a sympathetic dysfunction in the dermatomeubserving pain sensation from the affected shoulder.ecchio et al19 reported that differences in skin tem-erature distribution were found in 82% of subjectsith adhesive capsulitis, and nearly 75% of these

ubjects had reduced skin temperatures. They alsotudied patients with rotator cuff tendinitis but foundo consistent patterns in shoulder skin temperatures.urthermore, they determined that thermography isuestionable for the assessment of rotator cuff tendi-itis. Unlike our study, however, they did not investi-ate the patients’ clinical and operative findings.

Voloshin et al20 found histologic evidence of in-ammation in the subacromial bursa of all patientsith subacromial impingement and a full-thickness

otator cuff tear, whereas no or only mild inflamma-ion was found in the normal control subjects. In ourtudy, evidence of inflammation with bursitis andynovitis was not correlated with the thermographicndings. This result may have been caused by theigh incidence of bursitis and synovitis found in pa-ients with impingement syndrome. The relationshipetween inflammation and the DITI findings cannot belearly explained in our study.

Our study found a correlation between a de-reased range of motion and hypothermia. This resultan be explained by the fact that localized muscletrophy is caused by shoulder immobility. Fujino etl9 ascertained that muscle atrophy in vivo generatestructural alterations in the capillary network and thatpoptosis appears to occur in the endothelial cells of

he muscle capillaries. When structural alterationsnd apoptosis of the capillaries occur after muscletrophy, blood flow to the capillary would be de-reased, allowing the concomitant hypothermia to beetected. In our study, we could not detect atrophyirectly, but a decreased range of shoulder motionay reflect muscle atrophy and the concomitant hy-othermia detected by DITI.

In the 5 ROIs around the shoulder, the LAT ROI was

orrelated with the range of foreword elevation, and

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L and PL ROIs were correlated with the range ofxternal rotation. The rotator cuff and shoulder abduc-or muscles are located on the lateral (middle portionf the deltoid), anterolateral (subscapularis, anteriorortion of the deltoid), and posterolateral (infraspina-

us, teres minor, posterior portion of the deltoid) sidesf the shoulder. Thus, the reported results may reflect

able IV Comparison of clinical symptoms and the physical and op

Hypothermic (n � 51)*

linical findingsAge 50.5 � 10.6Duration (months) 18.8 � 43.5Male sex 27 (52.9)Trauma history 24 (47.1)

hysical findingsPain score (VAS) 6.58 � 0.74Neer’s impingement 43 (84.3)Hawkin’s impingement 37 (72.5)Coracoid impingement 8 (15.7)SS/GTT tenderness 36 (70.6)AC tenderness 7 (13.7)LHB tenderness 14 (27.5)

ange of motionForward elevation 118.6° � 30.8°§

External rotation 47.8° � 26.1°§

ER90 63.7° � 21.9°Cross-body adduction 26.9° � 5.1°Lateral rotation¶ 8.4 � 3.5Internal rotation¶ 8.6 � 3.9perative findingsRotator cuff tear 25 (49.0)Bursitis 41 (80.4)Synovitis 46 (90.2)

AS, Visual Analog Scale; SS/GTT, supraspinatus and greater tuberosity;otation at a 90° abduction.Categoric values are expressed as number (%); continuous values as meaP by Pearson �2 test.P by 1-way analysis of variance.Different from hyperthermic and normal group by Bonferroni post hoc testP � .05.For lateral rotation, the ear level was converted to 1, C1 to 2, C2 to 3, ano 7.

able V Correlation between shoulder range of motion and digitalnfrared thermographic imaging findings in hypothermic groups

Region Forward elevation* External rotation*

nteromedial �0.047 0.050nterolateral 0.208 0.313†

osteromedial 0.162 0.276osterolateral 0.267 0.334†

ateral 0.308† 0.247

Values are Pearson correlation coefficients.P � .05 by Pearson linear correlation analysis.

trophy of these muscles. d

Many investigators have used thermography as anbjective diagnostic tool for pain. Fischer8 reported

hat thermography could demonstrate discoid-shapedot spots over trigger points in patients with myofas-ial pain syndrome. Kruse et al14 pointed out thesefulness of thermography after the detection of arigger point with hyperthermia and temperature re-uction after trigger point compression. However,adhakrishna and Burnham17 claimed that thermog-aphy could not be used to diagnose myofascialrigger points because the skin temperature of triggeroints did not correlate with pressure sensitivity. Ther-ography is used in dentistry to detect arthralgia andotion limitation of the temporomandibular joint.2,12

owever, Fikackova et al7 reviewed the previoustudies on thermography in the diagnosis of temporo-andibular joint arthralgia and ultimately concluded

hat thermography should not be recommended foroutine use as a diagnostic modality.

Our study showed no correlation between shoul-

e findings listed according to group classification

erthermic (n � 22)* Normal (n � 27)* P

54.5 � 10.1 52.4 � 13.1 .363†

25.1 � 39.8 27.9 � 34.9 .614†

12 (54.5) 16 (59.3) .866†

9 (40.9) 6 (22.2) .099†

6.55 � 0.77 6.56 � 0.91 .985‡

16 (72.7) 23 (85.2) .659†

13 (59.1) 21 (77.8) .472†

2 (9.1) 4 (14.8) .787†

18 (81.8) 14 (51.9) .095†

4 (18.2) 6 (22.2) .608†

5 (22.7) 10 (37.0) .463†

133.6° � 25.9° 136.9° � 29.4° .021‡�

61.2° � 19.2° 61.2° � 24.4° .036‡�

70.0° � 13.8° 74.2° � 16.8° .079‡

24.0° � 4.4° 24.9° � 4.8° .136‡

9.1 � 2.8 9.3 � 2.0 .400‡

7.8 � 4.3 9.5 � 2.9 .143‡

16 (72.7) 17 (63.0) .141†

17 (77.3) 21 (77.8) .945†

18 (81.8) 20 (74.1) .278†

acromioclavicular joint; LHB, long head of biceps brachii; ER90, external

ndard deviation.

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er pain and DITI findings. One possible explanation

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or this result is that thermography itself cannot iden-ify pain, as described. In addition, the pain thresholday be decreased in patients with an impinged shoul-er who have stopped working because they haveeceived worker’s compensation.

Local inflammation around the shoulder may influ-nce the results of the hyperthermic and normalroups. Because the patients in the normal and hy-erthermic groups might have muscle atrophy and a

imitation of motion, they cannot be reflected in DITInalysis because hyperthermia occurring after inflam-ation can offset hypothermia. This is the limitation ofITI.A limitation of our study is the restricted viewing

ngles from the imaging. The key muscle affected inmpingement syndrome is the supraspinatus, whichontacts the coracoacromial arch, but the location ofhe supraspinatus in the coracoacromial arch cannote routinely detected with DITI. Furthermore, we didot measure the muscle power around the impingedhoulder, and as a result, we could not determine theorrelation between muscle power and the DITI find-ngs.

To better clarify the usefulness of DITI in the treat-ent of impingement syndrome, patient follow-up af-

er surgical management is needed. With successfulreatment, patients in the hypothermic group willhow normal temperatures as a result of improveduscle atrophy, and patients in the hyperthermicroup can also be normalized, with a decrease in

nflammation.

ONCLUSION

Our study showed that DITI is a useful tool to reflecttiffness of the shoulder objectively in impingementyndrome before arthroscopic subacromial decom-ression is performed. However, this tool can only bepplied in cases with a hypothermic thermal patternnd not in cases with normothermic and hyperthermic

hermal patterns. No relationship was found betweenain and DITI findings. To clarify the effectiveness ofITI, patients with impingement syndrome need to be

ollowed up after surgical management.

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