Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : AE01 - AE03 Full Version

Shoulder Impingement and its Association with Acromial Morphology- A Review


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/51462.16470
Rashmi C Goshi, K Pushpalatha

1. Assistant Professor, Department of Anatomy, JSS Medical College, Mysuru, Karnataka, India. 2. Professor and Head, Department of Anatomy, JSS Medical College, Mysuru, Karnataka, India.

Correspondence Address :
Dr. Rashmi C Goshi,
Assistant Professor, Department of Anatomy, JSS Medical College, Mysuru-570015, Karnataka, India.
E-mail: rashmicgoshi@jssuni.edu.in

Abstract

Shoulder with its chronic disability recognized by impingement of the rotator cuff beneath the coracoacromial arch. Varying acromial morphology revealed alterations attributable to mechanical impingement. The undersurface of the anterior part of the acromion and the front lip were always implicated. Extrinsic factors caused impingement and tendonopathy, with the antero-lateral acromion 'impinging' on the superior surface of the rotator cuff. The present review clearly describes the acromial morphology and its role as extrinsic causative factor in shoulder impingement. Treatment options for confirmed impingement range from analgesics and physiotherapy to injectable therapy and, open and arthroscopic surgery. In most studies, the results of arthroscopic subacromial decompression are positive, and data suggest that, the operation minimises the occurrence of rotator cuff injuries when compared to a control group. Complete acromionectomy and lateral acromionectomy yielded dismal results, prompting researchers to investigate the undersurface of the acromion in the development of impingement syndrome. There are however contradictory studies discussing the role of extrinsic and intrinsic causative factors of impingement.

Keywords

Acromion process, Arthroscopy, Rotator cuff

Shoulder is inherently unstable with wide range of movements and require bones, muscles and ligaments for support. The relatively short lever arm of the shoulder muscles operating on the substantially longer lever arm of the upper limb, often with additional load in the hand, results in extremely high loads via the tendons and strong response forces across the joint surfaces, causing shoulder pain (1).

Impingement is due to varying morphology of acromion process resulting in 'painful shoulder'. When the arms abduct at 90 degree and internally rotate at 45 degree, the supraspinatus tendon is closest to the anterior inferior border of the acromion, and the subacromial gap width changes. Because of the reduced space, the tendon is exposed to friction, resulting in a painful arc of 60 to 120 degree on abduction, weakening, and a partial loss of movement in the affected shoulder. The pain worsens at night and with overhead shoulder movements, resulting in functional impairment. With the use of conventional x-rays, early detection and care of disease can assist to limit disease development and its impact on everyday life (1).

External factors such as the prominence of the anterior-inferior acromion and the development of bony spurs extending into the coraco-acromial ligament, particularly anterior degenerative spurs, were once assumed to be the cause of primary impingement of the rotator cuff tendons. Many investigations support the hypothesis that, it was solely a mechanical process caused by extrinsic wear of the bursal surface of the tendon beneath the superior arch of the acromion (2).

Seagger RM and Wallace AL mentioned that, Biglani classified acromion radiologically into three types, flat, curved and hooked depending on the morphology of acromion process (2). According to Seagger RM and Wallace AL (2), and Neer CS (3), shoulder impingement can be studied under three stages:

Stage 1- Inflammation, oedema, and bleeding of the conjoint tendon in people under the age of 25, which is reversible if treated conservatively.

Stage 2- Continuation of Stage 1, although the symptoms are consistent. Patients between the age of 25 to 40 years are affected.

Stage 3- Affect patients more than 40 years. It includes partial or complete tear of rotator cuff due to chronic repetitive mechanical irritation to the conjoint tendon (2).

Shoulder impingement and rotator cuff tear are quite common and is treated surgically (2). The cause is still under debate. The dispute centres on two potential causes of shoulder impingement are intrinsic degenerative alterations in the tendons and extrinsic mechanical compression caused by the acromion process. One of the important factor in shoulder impingement syndrome is morphometry of acromion process (1),(2).

Discussion

In 1972, Neer CS (3) was the first person to describe impingement. It accounts for approximately 70% of shoulder diseases.

According to the main theory for rotator cuff impingement syndrome, there are anatomical and functional contributing elements (supraspinatus, infraspinatus, teres minor and subscapularis). The anatomical causes include inclination of the acromion process along with its shape. With conditioning and fitness, exact diagnosis of pathologic lesions is challenging due to individual differences in shoulder morphology and degree of shoulder laxity. On other view, rotator cuff tears due to degenerative changes of tendon has been described in 1931, by Codman. The supraspinatus syndrome is caused by compression of the bursa and rotator cuff tendons under the acromion. Previous literature successfully reported that, treatment by anterior acromioplasty in 95% of cuff tears caused by mechanical impingement (4).

Bigliani LU et al., (5), Nicholson GP et al., (6), Shah NN et al., (7), Gill TJ et al., (8), proposed both above theories which have been supported in numerous publications. Vitale MA et al., (9), stated that there has been a substantial increase in incidence of acromioplasty in the United States, which is still the standard operative treatment for impingement lesions. As per previous reports, indication for acromioplasty is generally supported by typical changes in acromial morphology on standard radiographs (3),[4,][10,](11),(12),(13),(14).

Acromial morphological features which can be evaluated in impingement:

Acromial type: It is determined by keeping the acromion on flat surface and measuring from anterior margin to posterior margin. As in (Table/Fig 1), 'A' represented anterior point and 'B' represented posterior point of acromion process. Two straight lines were drawn touching the anterior and posterior points of acromion process. The distance 'h' from the summit of two lines to flat surface was measured. Anterior angle was marked as 'α' and posterior angle as 'β' (15).

On morphometric basis, the acromion process was characterized as:

Type I: h ≤2 mm;
If h >2 mm,
Type II: β/α <1.5
Type III: β/α>1.5 (15)

Types 2 and 3 acromions were quantitatively separated by Epstein RE et al., (16), whereas type 1 and 4 acromions were designated according to Bigliani LU et al., (11). Types 1 and 4, as well as Types 2 and 3, are identified using the same three anatomic landmarks and a similar geometric technique Stehle J et al., (17). According to modified Epstein classification, types were given to acromion process with following criteria (16):

Type 1: Height that is less than or equal to 2% of acromial length.
Type 2: The highest point was above the middle third of the acromial length and the height was larger than 2% of the acromial length.
Type 3: As per J. Stehle et al.,) (17) finding the highest point was above the anterior third of the acromial length and that the height was larger than 2% of the acromial length.
Type 4: The undersurface's lowest point was under the acromial length (Table/Fig 2) (17).

A line connecting the most caudal borders of the acromial undersurface was manually drawn and its length was calculated using para saggital MR images for acromial type assessment. With the help of two orthogonal lines, the line was then separated into three equal-length parts. After that, the angle between the anterior third and the posterior two-thirds of the acromion was calculated (18).

Angle between anterior third and posterior two third was 10 degree or less, it’s Type 1 and if it’s 11-20 degree-, it was called Type 2.

If >20 degree, then angle between the posterior third and the anterior 2/3rd was further measured, if this latter angle was 10 degree or less, type 3 acromion was defined and if >10 degree this would be type 4 acromial shape (18).

Maximum acromial length: Distance from midpoint of posterior border to tip of acromion process (19).

Acromial slope [Table/Fig-3A]: According to Bigliani LU et al., (11) and Kitay GS et al., (20) the acromial slope (AS) measured on outlet-view radiographs. A line was drawn from the most anterior point of the inferior acromion to the midway point on the inferior acromion to determine the length. Another line is drawn from the inferior acromion's most posterior point to the same midway point. These two lines make an angle (δ) that measures AS (4).

Acromial tilt [Table/Fig-3B]: The Acromial Tilt (AT) was determined on outlet-view radiographs by Kitay GS et al., (20) and Aoki M et al., (10). A line traced from the inferior acromion's most posterior point to its most anterior point. A second line is drawn from the inferior acromion's most posterior point to the coracoid process's inferior tip. The Acromial tilt is the resultant angle (4).

Lateral acromial angle [Table/Fig-3C]: The Lateral Acromial Angle (LAA) is measured using true anteroposterior radiographs, according to Banas MP et al. (12). The glenoid surface is represented by a single line drawn along the superior and inferior most lateral points of the glenoid. Another line is drawn parallel to the underside of the acromion. The LAA is represented by the angle formed by these two lines (4).

Acromion index [Table/Fig-3D]: According to Nyffeler RW et al., (21), the Acromion Index (AI) measured on true anteroposterior radiographs. It was denoted by:

The distance between the glenoid plane and the acromion (GA)/ the glenoid plane and the lateral aspect of the humeral head (GH). The greater the acromion's extent, the higher the AI (4).

Acromial thickness: The widest portion of the acromion measured is acromial thickness (19).

Acromio-humeral distance: It's the distance between the acromion's underside and the humeral head's superior surface (22).

Findings of various studies are described in (Table/Fig 4) (5),(10),(11),(12),(14),(20),(21),(23),(24),(25).

The classification of acromial morphology is still commonly utilised in clinical practise and plays a significant role in deciding whether or not to have acromioplasty. However, the measurement's general applicability and interobserver reliability remain unknown. As a result, these assessment instruments require more research and have yet to be adopted into the standard of rotator cuff evaluation (25).

When interpreting opaque shadows on radiographs, association of subacromial enthesophytes with acromial morphology and rotator cuff tears should be borne in mind. The location and size of enthesophytes, acromial shape and rotator cuff status will aid the clinician to decide the type of surgery. Type III found to be predominant in impingement syndrome. Cuff tears involving total tears induce radiological Acromiohumeral Distance (AHD) of <6 mm (22). Impingement and rotator cuff tears are more common in people with a low lateral acromial angle and a considerable lateral extension of the acromion. Only patients with rotator cuff injuries had an excessively hooked anterior acromion and a LAA of less than 70° (4).

The key anatomical aspects of the scapula that can restrict the space available for the supraspinatus tendon appear to be lateral acromial overhang, lateral coracoids angle, and coraco acromion arch angle. These features can be thought of as predisposing anatomical factors for supraspinatus tears, to which intrinsic and extrinsic secondary compression variables (age-related acromial osteophyte) can be added. Degenerative alterations are more directly linked to the acromion's slope and length, as well as the arch's height. The type III acromion is involved in 62-66 percent of rotator cuff rupture instances (22). To refine the link between rotator cuff tears and the key anatomical features of the supraspinatus outlet, a clinical anatomy investigation based on CT or MRI definition of the subacromial canal in specimens with known supraspinatus tendon damage status would be required (4).

Conclusion

Knowledge of this review includes scope for further investigation to incorporate these measurement tools into the main stream of rotator cuff evaluation. It also might benefit the orthopaedician during surgical repair around joint. It is also helpful to anthropologists on evaluation of acromion and useful to forensic experts in determination of gender from acromial morphology.

References

1.
Akram M, Pasha IF, Shah SF, Farooqi FM, Awais SM, Types of Acromion and its assosciation with Shoulder Impingement Syndrome. Annals. 2014;20(2):144-48.
2.
Seagger RM, Wallace AL, Degenerative rotator cuff disease and impingement, Orthopaedics and Trauma, 2010 Elsevier Ltd: 1-10. [crossref]
3.
Neer C S, 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg (Am). 1972;54(1):41-50. [crossref]
4.
Balke M, Schmidt C, Dedy N, Banerjee M, Bouillon B, Liem D. Correlation of acromial morphology with impingement syndrome and rotator cuff tear. Acta Orthopaedica. 2013; 84(2):178-183. [crossref] [PubMed]
5.
Bigliani LU, Ticker J B, Flatow E L, Soslowsky L J, Mow V C. The relationship of acromial architecture to rotator cuff disease. Clin Sports Med. 1991;10(4):823-38. [crossref]
6.
Nicholson G P, Goodman D A, Flatow E L, Bigliani L U. The acromion: Morphologic condition and age-related changes. A study of 420 scapulas. J Shoulder Elbow Surg. 1996;5(1):1-11. [crossref]
7.
Shah N N, Bayliss N C, Malcolm A. Shape of the acromion: Congenital or acquired-A macroscopic, radiographic, and microscopic study of acromion. J Shoulder Elbow Surg. 2001;10(4):309-16. [crossref] [PubMed]
8.
Gill T J, McIrvin E, Kocher M S, Homa K, Mair S D, Hawkins R J. The relative importance of acromial morphology and age with respect to rotator cuff pathology. J Shoulder Elbow Surg. 2002;11(4):327-30. [crossref] [PubMed]
9.
Vitale M A, Arons R R, Hurwitz S, Ahmad C S, Levine W N. The rising incidence of acromioplasty. J Bone Joint Surg (Am). 2010;92(9):1842-50. [crossref] [PubMed]
10.
Aoki M, Ishii S, Usui M. The slope of the acromion and rotator cuff impingement. Orthop Trans. 1986;10:228.
11.
Bigliani L U, Morrison D S, April E W. The morphology of the acromion and its relationship to rotator cuff tears. Orthop Trans. 1986;10:228.
12.
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DOI and Others

DOI: 10.7860/JCDR/2022/51462.16470

Date of Submission: Jul 19, 2021
Date of Peer Review: Sep 14, 2021
Date of Acceptance: Jan 05, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 21, 2021
• Manual Googling: Aug 04, 2021
• iThenticate Software: Apr 21, 2022 (51%)

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