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The Effects of Vitamin D in Patients with Subacromial Impingement Syndrome/Subakromial Sikisma Sendromlu Hastalarda D Vitaminin Etkileri.


Subacromial impingement syndrome (SAIS) is a common reason for shoulder pain (1). SAIS is a spectrum of pathologies, including subacromial bursitis, rotator cuff tendinopathy, and rotator cuff tears (2, 3). SAIS has a progressive pathology in general (4). Bone disorders, muscle weakness, deterioration of the scapula humeral rhythm, poor posture, and inflammation in the bursa are the possible mechanisms of SAIS (2-5). Furthermore, it has been shown that inflammatory cytokines, matrix metalloproteinases (MMPs), and cyclo-oxygenases increased in the subacromial bursa of patients with SAIS and rotator cuff disease (6, 7). Therefore, mechanical factors as well as inflammatory processes are involved in the pathophysiology of SAIS (8).

Vitamin D has an important role in the muscle metabolism and functions. It supports protein synthesis and muscle cell growth. The relation of vitamin D with muscle mass, strength, and functions has been shown in many studies (9-11). Vitamin D deficiency results in degenerative changes in type II muscle fibers, including rotator cuff muscles, and hence muscles tend to tear (12). Vitamin D has an important role in muscle performance. Oh et al. (10) found that vitamin D decreased the fatty degeneration of the supraspinatus and infraspinatus while increasing muscle performance in patients with shoulder problems. It can also have a role in tendon remodeling through MMPs, and low vitamin D level may delay the recovery of rotator cuff tendon repair by upregulating MMP-9 (13-15).

The mechanical factors arising from the musculoskeletal system and various inflammatory mechanisms are responsible for SAIS, as mentioned above. Also, vitamin D has important roles in the musculoskeletal system and inflammatory processes (16). Therefore, it would be beneficial to investigate the clinical effects of vitamin D on SAIS. We aimed to investigate the effects of vitamin D on pain, disability, and shoulder range of motion (ROM) in patients with SAIS.



Patients who were admitted to the physical medicine and rehabilitation outpatient clinic between January 01, 2014 and June 30, 2014 and had shoulder pain due to SAIS were retrospectively assessed in this study. The diagnosis of SAIS was based on the clinical findings and magnetic resonance imaging (MRI). SAIS was defined as positive shoulder tests for painful arc, Neer, and Hawkins tests and subacromial bursitis and/or rotator cuff tendon pathology in MRI. Patients who had a detailed physical examination (shoulder ROMs and positive for painful arc, Neer, and Hawkins shoulder tests), clinic evaluation (shoulder visual analog scale [VAS] disease arm shoulder hand [DASH] score), laboratory tests (liver and renal function tests, calcium, phosphorous, 25-OH vitamin D, and parathyroid hormone [PTH]), and subacromial bursitis and/or rotator cuff tendon pathology in MRI were included in the study.

Patients who had infectious shoulder arthritis, liver and renal function disorders, any rheumatologic (rheumatoid arthritis or spondyloarthropathy) and neurologic disorders, intraarticular fracture, a history of shoulder operation, adhesive capsulitis, calcific tendinitis, tip 3 acromion, bilateral shoulder lesion, full thickness rupture of rotator cuff tendons, and incomplete documentation were excluded.


Age, gender, the affected shoulder side, duration of shoulder pain, shoulder ROMs for abduction, flexion, external rotation and internal rotation, blood level of 25-OH vitamin D, shoulder pain VAS, and DASH scores were recorded. The blood level of 25-OH vitamin D was used to determine the vitamin D level in patients.

Shoulder pain was assessed using VAS (0-10 cm scale; 0 means no pain, 10 means severe pain). DASH is a 30-item questionnaire. It evaluates pain, tingling, stiffness, weakness, social function, work, sleep, and self-confidence in patients (17).

The immunechemiluminometric assay was used to determine the vitamin D level in patients. The serum concentration of PTH was determined using an electrogenerated chemiluminescence immunoassay technology.

Patients were divided into three groups according to previous literature (18, 19): Group 1: 25-OH vitamin D <10 ng/mL, Group 2: 25-OH vitamin D 10-20 ng/mL, Group 3: 25-OH vitamin D >20 ng/mL. The demographic features, ROMs, VAS, and DASH scores were compared. Furthermore, the correlations of 25-OH vitamin D with ROMs, VAS, and DASH scores were analyzed.

This study was approved by the local ethics committee of Bakirkoy Dr. Sadi Konuk Trainining and Research Hospital and was conducted in accordance with the ethical standards in the Declaration of Helsinki.

Statistical Analysis

The statistical analysis was performed using the Number Cruncher Statistical System 2007 &PASS (Power Analysis and Sample Size) 2008 Statistical Software (Utah, USA). When data of the study were assessed, descriptive statistics (mean, standard deviation, median, frequency, ratio and minimum and maximum) were reported. In comparison to quantitative data, non-normally distributed variables were compared between the two groups using the Mann-Whitney U test and between two or more groups using the Kruskal-Wallis test. The Spearman's Correlation analysis was performed to assess the relationship of non-normally distributed variables. Results were evaluated at a significance level of a p<0.05.


Eighty patients who met the study criteria were included in this study. The patients' mean age was 51.99[+ or -]11.14 years, and the symptom duration was 6.32[+ or -]5.89 months. There were 55 (68.8%) female and 25 (31.3%) male patients. There were 22 patients in Group 1, 43 patients in Group 2, and 15 patients in Group 3.

Table 1 shows the comparison of demographic features, shoulder ROMs, VAS, and DASH scores of the three groups. There was a significant difference in VAS between the groups. The shoulder VAS was significantly higher in Group 1 compared to Group 3 (p=0.01). No significant difference was observed for shoulder VAS between Groups 1 and 2 or between Groups 2 and 3. In addition, there was a statistically significant difference in the PTH levels between the groups (p=0.024). According to binary comparisons, PTH in Group 1 was significantly higher than that in Group 3 (p=0.005). No statistically significant differences were detected for PTH between Groups 1 and 2 or Groups 2 and 3 (p>0.05). There was no significant difference in the DASH score and shoulder ROMs between the groups. The correlation analyses of 25-OH vitamin D with shoulder ROMs, shoulder VAS, and DASH scores are shown in Table 2. A significant negative correlation was detected between 25-OH vitamin D and VAS.


The results of this study demonstrated that severe deficiency of vitamin D (25-OH vitamin D <10 ng/mL) increases shoulder pain in SAIS. In addition, it was observed that shoulder pain increases in SAIS as the level of vitamin D decreases. However, according to our results, there was no relation between vitamin D and disability or vitamin D and shoulder ROM in SAIS. To the best of our knowledge, this is one of the first studies which investigated the clinical relations between SAIS and vitamin D.

Subacromial impingement syndrome (SAIS) is often accompanied by subacromial bursitis, rotator cuff tendinosis, and tendon tears (2). Subacromial bursitis is the major reason of pain and disability in SAIS (8). It has been shown that inflammatory cytokines (interleukin [IL]-1, IL-6, tumor necrosis factor [TNF-[alpha]]), MMPs, and cyclo-oxygenases increase in the subacromial bursa of patients with SAIS (6, 7, 20). SAIS and rotator cuff pathologies can be painful and associated with inflammation (6, 16). Particularly, substance P and IL-1 in the subacromial bursa were correlated with pain (8, 20). The suppression effect of vitamin D on inflammatory mediators (IL-1 and TNF-a) and MMPs has been reported in previous studies (13, 21-24). According to the results of this study, vitamin D is negatively correlated with shoulder pain in SAIS. One of the possible mechanisms may be the suppressive effect of vitamin D on inflammatory cytokines and enzymes. In addition, it was shown that vitamin D promoted the proliferation of tendon-derived cells that were obtained from the supraspinatus muscle (25). Hence, vitamin D has crucial effects on the tendons in the subacromial space. The reduction of vitamin D level in the blood may cause PTH to rise. In this study, PTH is significantly higher in Group 1 than in Group 3. PTH causes weakness of the bone-tendon junction by inducing general osteoporosis with subperiosteal bone resorption (26). Increased PTH in severe vitamin D deficiency may also negatively affect the tendons passing from subacromial space.

Pain due to vitamin D deficiency is usually seen in the low back, pelvis, hip, back, and rib bones (27). The relationship between low vitamin D levels and pain in patients with non-specific musculoskeletal pain has been shown in previous studies (28-31). Also, replacement therapy for vitamin D deficiency improves pain and other musculoskeletal symptoms in patients with widespread pain (31). Vitamin D has important roles in the inflammatory process and musculoskeletal system; therefore, the deficiency of vitamin D may also play role in SAIS, which is closely related with both the systems.

Vitamin D is also one of the most common nutritional deficiencies in the world (32). In this study, vitamin D levels were deficient in 81% of patients with SAIS. Therefore, low vitamin D levels should be considered for patients who have severe shoulder pain in SAIS.

According to our results, no significant relation was observed between ROMs and vitamin D levels or between disabilities of patients and vitamin D levels. Similar to our results, it has been shown in another study (33) that vitamin D level was not related to the functional status in patients who had undergone an arthroscopic rotator cuff repair. In contrast, Oh et al. (10) reported that there was a negative association between vitamin D level and fatty degeneration of rotator cuff muscles in patients with full-thickness rotator cuff tears versus those with other shoulder lesions without a tear, and they concluded that low serum vitamin D level might have more severe rotator cuff tear. There are conflicting results of studies that have investigated the effects of vitamin D on shoulder pathologies in literature.

To the best of our knowledge, the effects of vitamin D on disability, ROMs, and pain in SAIS have not been investigated previously. This was the primary aim of our study. The study has few limitations. First, this is a retrospective study and data were obtained from patient records. Secondly, when patients were divided into three groups according to the vitamin D status, the number in Group 3 was less than other groups. The ratio of female and male patient was 68.8% and 31.2%, respectively, and this difference was similar to a study that investigated the demographic features in SAIS (34). Further studies that investigate the clinical features of SAIS after vitamin D supplements are given will provide more detailed information. Also, it will be useful to investigate the local effects of vitamin D on soft tissues of the subacromial space.


According to our findings, severe deficiency of vitamin D may increase shoulder pain in patients with SAIS. Also, vitamin D level is inversely correlated with shoulder pain in SAIS. Therefore, vitamin D level may be monitored in patients with severe pain due to SAIS.

Ethics Committee Approval: Authors declared that the research was conducted according to the principles of the World Medical Association Declaration of Helsinki "Ethical Principles for Medical Research Involving Human Subjects", (amended in October 2013).

Informed Consent: Informed consent was not taken from patients due to the retrospective nature of the study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept - B.Y.K., M.V., S.E., A.N.B., B.O.; Design - B.Y.K., M.V., S.E., A.N.B., B.O.; Supervision - B.Y.K., M.V., S.E., A.N.B., B.O.; Resources - B.Y.K., M.V., S.E., A.N.B., B.O.; Data Collection and/or Processing - B.Y.K., M.V., S.E., A.N.B., B.O.; Analysis and/or Interpretation - B.Y.K., M.V., S.E., A.N.B., B.O.; Literature Search - B.Y.K., M.V., S.E., A.N.B., B.O.; Writing Manuscript - B.Y.K., M.V., B.O.; Critical Review - B.Y.K., M.V., S.E., A.N.B., B.O.

Conflict of Interest: The authors have no conflict of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

Etik Komite Onayi: Yazarlar calismanin World Medical Association Declaration of Helsinki "Ethical Principles for Medical Research Involving Human Subjects", (amended in October 2013) prensiplerine uygun olarak yapildigini beyan etmislerdir

Hasta Onami: Calismanin retrospektif tasarimindan dolayi hasta onami alinamamistir.

Hakem Degerlendirmesi: Dis bagimsiz.

Yazar Katkilari: Fikir - B.Y.K., M.V., S.E., A.N.B., B.O.; Tasarim - B.Y.K., M.V., S.E., A.N.B., B.O.; Denetleme - B.Y.K., M.V., S.E., A.N.B., B.O.; Kaynaklar - B.Y.K., M.V., S.E., A.N.B., B.O.; Veri toplanmasi ve/veya islemesi - B.Y.K., M.V., S.E., A.N.B., B.O.; Analiz ve /veya yorum - B.Y.K., M.V., S.E., A.N.B., B.O.; Literatur Taramasi - B.Y.K., M.V., S.E., A.N.B., B.O.; Yaziyi Yazan - B.Y.K., M.V., B.O.; Elestirel Inceleme - B.Y.K., M.V., S.E., A.N.B., B.O.

Cikar Catismasi: Yazarlarin beyan edecek cikar catismasi yoktur.

Finansal Destek: Yazarlar bu calisma icin finansal destek almadiklarini beyan etmislerdir.


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Betul Yavuz Keles (1) [iD], Meltem Vural (2) [iD], Sedef Ersoy (2) [iD], Burcu Onder (1) [iD], Ayse Nur Bardak (1) [iD]

(1) Department of Physical Medicine and Rehabilitation, University of Health Sciences Istanbul Physical Medicine Rehabilitation Training and Research Hospital, Istanbul, Turkey

(2) Department of Physical Medicine and Rehabilitation, University of Health Sciences Istanbul Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey

Cite this article as: Yavuz Keles B, Vural M, Ersoy S, Onder B, Bardak AN. The Effects of Vitamin D in Patients with Subacromial Impingement Syndrome. JAREM 2019; 9(2): 61-5.

Corresponding Author / Sorumlu Yazar: Betul Yavuz Keles,

E-mail / E-posta:

Received Date / Gelis Tarihi: 29.04.2018 Accepted Date / Kabul Tarihi: 10.07.2018

DOI: 10.5152/jarem.2019.2126
Table 1. Demographic and clinical characteristics of groups

                             Group 1          Group 2

Age, years                    47 (34-75)       53 (24-73)
Duration of disease, months    5 (2-24)         4.5 (1-36)
Affected side, right/left     14/8             23/20
Flexion, degrees             150 (90-180)     140 (20-180)
Abduction, degrees           140 (60-180)     120 (30-180)
IR, degrees                   70 (40-90)       60 (10-90)
ER, degrees                   60 (30-90)       60 (15-90)
VAS (0-10)                     8 (3-10)         7 (0-10)
DASH                          66 (25-102)      78 (38-126)
PTH (pg/mL)                   50.1(17.9-114)   35.59 (18.2-198)

                             Group 3          p

Age, years                    50 (24-69)      0.183
Duration of disease, months    6 (2-24)       0.417
Affected side, right/left      9/6            0.722
Flexion, degrees             160 (90-180)     0,138
Abduction, degrees           150 (80-180)     0.157
IR, degrees                   70 (30-90)      0.084
ER, degrees                   50 (10-90)      0.939
VAS (0-10)                     6 (0-10)       0.022 (*)
DASH                          67 (41-119)     0.270
PTH (pg/mL)                   30 (22.7-44.1)  0,024 (*)

Values are expressed as median (minimum-maximum) or number of patients;
Group 1: 25-OH vitamin D <10 ng/mL, Group 2: 25-OH vitamin D 10-20
ng/mL, Group 3: 25-OH vitamin D>20 ng/mL; VAS: visual analog scale;
DASH: disease arm shoulder hand score; PTH: parathyroid hormone; IR:
internal rotation; ER: external rotation; (*) p<0.05

Table 2. Correlation analysis of shoulder roms, vas, and dash with
25-oh vitamin D

                    25-OH vitamin D
                     r      p

Flexion, degrees    -0.014  0.904
Abduction, degrees   0.099  0.404
IR, degrees         -0.113  0.344
ER, degrees         -0.086  0.468
VAS                 -0.308  0.006 (*)
DASH                 0.065  0.574
PTH (pg/mL)         -0.483  0.001 (*)

ROMs: range of motions; VAS: visual analog scale; DASH: disease arm
shoulder hand score; PTH: parathyroid hormone; IR: internal rotation;
ER: external rotation; (*) p<0.05
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2019 Gale, Cengage Learning. All rights reserved.

Article Details
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Title Annotation:Original Investigation / Ozgun Arastirma
Author:Keles, Betul Yavuz; Vural, Meltem; Ersoy, Sedef; Onder, Burcu; Bardak, Ayse Nur
Publication:Journal of Academic Research in Medicine
Article Type:Report
Date:May 7, 2019
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