J Shoulder Elbow Surg (2009) 18, 172-177

www.elsevier.com/locate/ymse

Impingement syndrome: Temporal outcomes of

nonoperative treatment
Craig A. Cummins, MDa,*, Lisa M. Sasso, MDb, Daniel Nicholson, MDb
a
b

Lake Cook Orthopaedic Associates, Barrington, IL

Department of Orthopaedic Surgery, Northwestern University Medical Center, Chicago, IL
Hypothesis: We prospectively studied patients with impingement syndrome to look at outcomes of
nonoperative treatment on a temporal basis.
Materials and methods: Temporal outcomes of 100 consecutive patients treated for impingement
syndrome were prospectively evaluated. All patients began a standardized, nonoperative treatment
protocol consisting of a subacromial steroid injection, followed by physical therapy.
Results: Data were available on 94 patients at the final two-year follow-up assessment. Overall, 74 of 94
patients did not require surgery. In that group, the average American Shoulder and Elbow Surgeons
(ASES) outcome score increased from 56 to 95, with an average decrease in the pain score from 4.8 to
0.6. Improvement was demonstrated in patient shoulder outcome scores (ASES score) and visual analog
pain scores between treatment initiation and the one-year follow-up assessment (p < .0001); no improvement was identified past one year. Of the non-surgical patients, 22 continued to have some shoulder pain.
Conclusion: Of patients with impingement syndrome treated nonoperatively, 79% did not require surgery
after two-year follow-up. Predictors of patients going on to surgical intervention included the total number
of subacromial steroid/lidocaine injections and patient response to the initial subacromial injection. Of the
patients not undergoing surgery, 30% continued to have some shoulder pain.
Level of evidence: Level 1; Prospective prognosis study, >80% follow-up.
2009 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Impingement syndrome; physical therapy; injections; surgery

Impingement syndrome is a common diagnosis seen by

orthopedic surgeons and primary care physicians.12 Clinically, patients with impingement syndrome report pain
located in the region of their shoulder and lateral aspect of
their upper arm. Although this shoulder pain may occur at
rest, it is typically exacerbated with elevation of the arm
overhead.7 Physical examination classically demonstrates
reproduction of patients shoulder pain by raising their arm
*Reprint requests: Craig A. Cummins, MD, Lake Cook Orthopaedic
Associates, 27401 W Highway 22, No. 125, Barrington, IL 60010.
E-mail address: ccraigacummins@hotmail.com (C.A. Cummins).

into the impingement arc (70 to 120 arm elevation).7 A

number of provocative tests have been described, each
representing variations of this maneuver.5,7,8 From an
anatomic standpoint, impingement syndrome refers to the
supraspinatus tendon impinging on the undersurface of the
anterior acromion as the arm is raised overhead.4,6,7
It is important to note that different pathologic entities
may coexist in patients with impingement syndrome.2,7,9
As an example, patients with subacromial bursitis, rotator
cuff tendinopathy, partial rotator cuff tears, and even small
full-thickness tears may all initially present to the clinician
with a diagnosis of impingement syndrome. Therefore,

1058-2746/2009/$36.00 - see front matter 2009 Journal of Shoulder and Elbow Surgery Board of Trustees.
doi:10.1016/j.jse.2008.09.005

Temporal outcomes of nonoperative treatment

although impingement syndrome represents the supraspinatus tendon impinging under the acromion, it does not
necessarily define the extent of the underlying pathologic
shoulder disorder. It is only after obtaining more data from
a thorough physical examination, imaging tests, or
arthroscopy that a more specific pathologic diagnosis
becomes clear.9
Regardless of the underlying pathology, most patients
who present with impingement syndrome respond favorably
to nonoperative treatment, with previous studies having
demonstrated success rates of approximately 70%.1-3,10 The
goal of this study was to assess patient outcomes over time
in a cohort treated with a standardized, best-practice,
nonoperative treatment program. We hypothesized that
patients with a clinical diagnosis of impingement syndrome
would demonstrate temporal improvement after a subacromial steroid injection and a standardized physical
therapy program. We also hypothesized that poorer
outcomes would be observed in patients who presented with
a higher pain score, longer history of symptoms, larger
number of comorbid medical conditions, and those
requiring multiple subacromial steroid injections to control
their symptoms.

Materials and methods

Data were collected prospectively on a cohort of 100 consecutive
patients treated by a single surgeon for a diagnosis of impingement syndrome. Inclusion criteria were a diagnosis of impingement syndrome in patients between the age of 35 and 65 years.
The diagnosis of impingement syndrome was determined from the
history, physical examination, and response to a diagnostic subacromial injection. Specifically, patients reported a history of pain
located in the lateral aspect of the shoulder and upper arm that was
aggravated with overhead activities. Physical examination
demonstrated reproduction of the shoulder pain with elevation of
the affected shoulder into the impingement arc. All patients
received a subacromial injection that included a local anesthetic
and steroid. A positive response to the subacromial injection was
defined as a 50% or greater reduction in pain during a repeat
impingement test performed 10 minutes after the injection.
Exclusion criteria included shoulder weakness that persisted after
injection, significant coexisting shoulder pathology (ie, instability,
acromioclavicular arthropathy, glenohumeral arthritis, adhesive
capsulitis), cervical spine pathology, a history of shoulder injections, previous shoulder surgery, or involvement in a related
workers compensation claim or litigation.
All patients were treated with a standardized nonoperative
treatment protocol that was deemed best practice from a literature
review and surgeon experience. The nonoperative protocol consisted of a subacromial steroid injection, followed by a 4-week
course of physical therapy. The subacromial injection was performed through a posterior approach, with the injectable solution
consisting of a mixture of methylprednisolone acetate (volume,
1 mL; concentration, 40 mg/mL) and 1% lidocaine (volume, 4
mL; concentration, 10 mg/mL).
After the injection, all patients were given a prescription for
a 4-week course of physical therapy with instructions for the

173
therapists to advance the patients to an exercise program at home.
A standardized physical therapy program was used, with the
therapists instructed to work within the patients level of pain and
with a gradual progression of exercises as tolerated. In particular,
the therapists were instructed to address issues that included
patients posture, associated muscle spasm, overall shoulder
mechanics, posterior capsular tightness, weakness of the rotator
cuff, and periscapular musculature. All physical therapy facilities
within the surrounding region were provided with the impingement syndrome physical therapy protocol.
At the initial assessment, data were collected on all patients
medical history as well as specific information pertaining to their
shoulder pain, including onset, duration, and etiology. All patients
also completed the validated American Shoulder and Elbow
Surgeons (ASES) shoulder assessment form10 at the initial
assessment as well as at the follow-up appointments at 6 weeks,
3 months, 6 months, 1 year, and 2 years. The final data point for
the operative group was the last visit before surgery.
Also at the initial assessment, findings were recorded of
a physical examination that evaluated shoulder motion, strength,
and laxity. It also involved a number of tests to assess for alternative shoulder diagnosis to include labral tears, biceps tears, and
acromioclavicular arthralgia. Patients were evaluated with radiographs of the affected shoulder. As part of the radiographic
assessment, the acromion shape and morphology was recorded
from the outlet radiograph as being flat, curved, or hooked.
Further diagnostic testing with ultrasound scans, computed
tomography (CT), or magnetic resonance imaging (MRI) was not
routine at the initial evaluation. However, further imaging tests
were performed in those who did not improve with nonoperative
treatment.
During the course of the investigation, some patients required
surgical treatment for the management of their shoulder pain and
dysfunction. Surgical indications included failure to improve with
a minimum of 3 months of nonoperative treatment. Surgery was
also considered if additional diagnoses were identified during the
treatment period (ie, rotator cuff tears) that were not appreciated
by the treating physician at the initial assessment. Data for
patients who underwent surgical management were collected at
the time of the surgery. Those undergoing surgery were defined as
having failed nonoperative treatment (negative outcome) for
statistical purposes.
Statistical comparisons were made between those patients with
a positive outcome and those with a negative outcome for their
response to the nonoperative treatment protocol. Specifically,
analyses were performed to determine if differences existed in
age, sex, side affected, duration of symptoms before treatment,
pain severity on presentation, number of coexisting medical
conditions, number of injections, and acromial morphology.
Continuous variables such as age were analyzed using 2-sided,
2-sample t tests; whereas, categoric variables such as coexisting
medical conditions were analyzed with c2 tests.
A statistical evaluation was performed to assess patient
outcomes for their pain response after the shoulder injection.
Statistical analysis included descriptive statistics, 1-way analysis
of variance (ANOVA) to assess the relationship between the VAS
scores and ASES scores across time, and a logistic regression
analysis to evaluate the relationship of the covariates to the
outcome variable of surgery. All statistical analyses were done
SAS 9.1 software (SAS Institute, Cary, NC). Statistical significance was set at a value of P  .05, with power set at 0.8.

174
This study did not undergo Institutional Review Board
approval.

C.A. Cummins, L.M. Sasso, D. Nicholson

Shoulder Pain Score

10

Results
Pain Score

2 Years

1 Year

6 Month

0
Time 0
6 Weeks
12 Weeks

Between June 2002 and September 2003, 94 patients (100

shoulders) who met the inclusion criteria were enrolled in
this investigation. Data were obtained for all 100 shoulders
at the initial assessment. An attempt was made to collect
data from all study participants at each time point. Shoulder
outcome data was collected on 84 shoulders at 6 weeks, 74
at 12 weeks, 90 at 6 months, 95 at 1 year, and 94 at the final
follow-up at 2 years or longer after the injection. The
average age at the onset of the investigation was 48.9  8.8
years, with 45% women and 55% of the affected shoulders
occurring in men. Sixty affected shoulders involved the
patients dominant arm (57 right, 43 left). At the time of
presentation, only 37 patients could recall an inciting event
that precipitated the development of their pain. The average
duration of symptoms before presentation was 8 weeks, with
54 patients reporting prior treatment with nonsteroidal antiinflammatory medications, and 18 having undergone physical therapy. No significant differences were noted in age,
gender, hand dominance, type of acromion, patient pain
scores, or ASES scores. At the initial presentation, the
average pain score was 4.7  2.0, and the ASES score was
56.4  16.5.
Physical examination demonstrated a positive impingement sign in all patients as well as a positive response to
local anesthetic injected in the subacromial space. Average
active range of motion at initial assessment was forward
flexion of 161  27 , external rotation of 57  14 with
the arm at the side, and 77  18 with the shoulder
abducted 90 . Average internal rotation was to the 11th
thoracic vertebra 5 vertebral levels. Strength assessment
on manual muscle testing (scale, 0 to 5) was abduction, 4.8
 0.4; external rotation, 4.9  0.3; and internal rotation, 5.0
 0.0. All patients demonstrated normal strength (5/5) after
the injection of a local anesthetic into the subacromial
space. None of the affected shoulders had findings
suggestive of coexisting shoulder or cervical pathology.
At the final 2-year evaluation, 20 shoulders had undergone surgical treatment because nonoperative treatment had
failed; however, 74 had not undergone surgery. Those
patients not requiring surgery experienced significant
improvement in their level of pain, ability to perform
activities of daily living, and ASES score between the
initial evaluation and the final 2-year assessment (mean
follow-up, 106  4 weeks; P < .001). Patients also
demonstrated temporal improvement in pain scores and
ability to perform activities of daily living up to 1 year after
the initiation of this investigation (Figures 1-4). Specifically, improvement in patient VAS pain scores occurred
between the initial and 6-week evaluations (4.8  1.9 to 2.7
 2.1, P < .0001), between the 6-week and 6-month

Time

B
VAS Pain
Score

Initial Visit

6 weeks

3 months

6 months

1 year

Initial Visit
6 weeks

****

3 months

****

NS

6 months

****

**

***

1 year

****

****

****

***

2 years

****

****

****

****

NS

Figure 1 (A) Mean visual analog scale (VAS) pain scores are
presented with the standard error (range bars) from baseline,
6 weeks, 12 weeks, 6 months, 1 year, and 2 years after the initiation
of treatment. (B) Significance of VAS scores: NS, no statistical
difference; ))P < .01, )))P < .001, and ))))P < .0001.

evaluations (2.7  2.1 to 2.0  2.1, P .02), and between

the 6-month and 1-year evaluations (2.0  2.1 to 0.9  1.5,
P .0002). No improvement was identified beyond 1 year
after the initial evaluation (P .33). Similar statistically
significant temporal improvement was identified for the
ASES shoulder score and the 10 questions assessing the
ability to perform activities of daily living that are part of
the standardized shoulder assessment form.11
At the 2-year evaluation, follow-up data were collected
on 74 shoulders that had not undergone surgery. Of those
74 patients, 52 reported a pain score of zero, 9 reported
a pain level at 1 or lower, 5 reported pain as 2 or lower, 5 as
3 or lower, 3 as 4 or lower, and no patient reported a pain
score exceeding 4 of 10. Overall, of the 94 those patients
available for the 2-year follow-up, 52 (55%) had a pain
score of zero and had not undergone surgery; whereas, 42
(45%) had undergone shoulder surgery or continued to have
some degree of shoulder pain.

Temporal outcomes of nonoperative treatment

175

American Shoulder and Elbow Society

Shoulder Assessment Score
(ASES Score)

Difficulty Reaching a High Shelf

None

100

Mild

60
Moderate
40

20

1 Year

2 Years

2 Years

1 Year

6 Month

Time 0
6 Weeks
12 Weeks

6 Month

Severe
Time 0
6 Weeks
12 Weeks

ASES Score

80

Time

Time

Difficulty Reaching a High Shelf

ASES Score
Initial Visit
Initial Visit

6 weeks

3 months

6 months

6 weeks

3 months

6 months

1 year

1 year

Initial Visit

Initial Visit

6 weeks

****

3 months

****

NS

6 months

****

**

***

1 year

****

****

****

****

2 years

****

****

****

****

6 weeks

***

3 months

**

6 months

****

1 year

****

****

****

2 years

****

****

****

***

NS

NS

Figure 2 (A) Mean American Shoulder and Elbow Surgeons

(ASES) shoulder assessment scores are presented with the standard
error (range bars) from baseline, 6 weeks, 12 weeks, 6 months,
1 year, and 2 years after the initiation of treatment. (B) Significance of results of ASES scores: NS, no statistical difference;
))P < .01, )))P < .001, and ))))P < .0001.

Univariate analyses were performed to assess possible

association between the outcome of the patients surgery
and the factors of preinvestigation duration of symptoms,
severity of pain at initial presentation, number of comorbid
medical diagnosis, and number of subacromial steroid
injections. Only the number of subacromial steroid injections was correlated with a negative outcome (P .0002).
In the nonoperative group, 10% received a second steroid
injection, whereas 65% of the operative group had received
more than 1 injection. Overall, 21 shoulders received
a second steroid injection (no patient had more than 2
injections), and 13 (62%) of these later underwent shoulder
arthroscopy. Duration of symptoms, severity of pain on
presentation, and number of comorbid medical conditions
did not correlate with patients having surgery.

NS

Figure 3 (A) Mean patient response to difficulty reaching

a high shelf with their affected arm is presented with the standard
error (range bars) from baseline, 6 weeks, 12 weeks, 6 months, 1
year, and 2 years after the initiation of treatment. (B) Significance
of results: NS, no statistical difference; )P < .05, ))P < .01,
)))P < .001, and ))))P < .0001.

Results from a repeat measures ANOVA demonstrated

a poorer pain response to the subacromial steroid injection
in those patients in whom nonoperative treatment failed (P
.007). Specifically, those patients who had operative
treatment demonstrated only a small improvement in pain
scores at 6 weeks after the injection (5.4  1.9 to 4.7 
2.3). In contrast, a larger improvement was identified in
those patients who were successfully treated nonoperatively (4.6  1.9 to 2.05  1.6; P .007; Figure 5).
In the 19 patients in whom nonoperative treatment failed,
12 (63%) had a pain score of 5 or greater at the 6-week
assessment after the injection. However, only 3 of the 64
patients (5%) who were successfully treated nonoperatively
had a pain score of 5 or greater (P < .001) at the same time
point.

176

C.A. Cummins, L.M. Sasso, D. Nicholson

Impingement Syndrome
Pain Score Verses Weeks Post Initiation
of Non-Operative Treatment

Ability to Sleep on Affected Side

None
10

Mild

Pain Level (VAS)

Moderate

2
2 Years

1 Year

6 Month

Time 0
6 Weeks
12 Weeks

Severe
0
0

B
Difficulty Sleeping on Affected Side

6 weeks

3 months

10

15

20

25

30

Weeks

Time

Initial Visit

6 months

1 year

Figure 5 Mean impingement syndrome pain scores are presented with the standard error (range bars) at baseline, 6 weeks,
12 weeks, and 6 months after the initiation of treatment. The
circles indicate the pain scores of all patients treated for
impingement syndrome in this investigation, the triangles identify
the pain scores in those patients who ultimately underwent
shoulder surgery, and the squares represent the cohort of patients
that were successfully treated nonoperatively.

Initial Visit
6 weeks

Discussion

****

3 months

***

NS

6 months

****

NS

1 year

****

***

****

**

2 years

****

****

****

****

NS

Figure 4 (A) Mean ability to sleep on the affected shoulder is

presented with the standard error (range bars) at baseline,
6 weeks, 12 weeks, 6 months, 1 year, and 2 years after the initiation of treatment. (B) Significance of results: NS, no statistical
difference; )P < .05, ))P < .01, )))P < .001, and ))))P <
.0001.

Twenty shoulders underwent arthroscopic surgery, with

the average time to surgical intervention from initiation of
treatment of 32.5 weeks. At the time of the arthroscopy, all
patients had findings consistent with impingement
syndrome, which included fraying on the undersurface of
the acromion or subacromial bursitis, or both. In 14 of 20
shoulders, additional diagnoses were identified before or at
the time of the surgery. Specifically, 6 had a small, fullthickness rotator cuff tear, 4 had a superior labral anterior to
posterior tear with instability of the biceps tendon attachment site, 1 presented with pain at the acromioclavicular
joint that was addressed with a distal clavicle resection,
4 had a partial biceps tear addressed surgically, adhesive
capsulitis developed in 1, and a suprascapular neuropathy
was diagnosed in 1 patient.

Impingement syndrome is a common shoulder disorder in

which the supraspinatus tendon impinges on the undersurface of the acromion as the arm is raised overhead.4,6,7
Patients in the current investigation were diagnosed with
impingement syndrome according to their history, physical
examination, and response to a diagnostic subacromial
injection. Advanced diagnostic imaging tests were not
required as part of the inclusion criteria. The investigation
was designed to simulate a typical presentation of a patient
with impingement syndrome to an orthopedic practice.
The diagnosis of impingement syndrome is often made in
the absence of advanced imaging modalities such as MRI.
Although these tests are useful to assess alternative diagnoses, they could introduce a selection bias to the investigation and potentially alter the results. Because many
patients in this study improved without further diagnostic
testing, the data suggest that advanced imaging tests may not
be necessary in many patients diagnosed with impingement
syndrome. However, a concern is that additional shoulder
diagnoses were identified in those patients who went on to
surgery. Additional diagnosis may have been present in some
patients who did not undergo surgery, but the significance of
potential missed diagnoses in this latter segment of patients is
unclear. However, our results support the concept of reevaluating those patients who respond poorly to nonoperative
treatment with advanced imaging to assess for alternative or
coexisting diagnosis.

Temporal outcomes of nonoperative treatment

The principles of treatment for impingement syndrome
have historically involved avoidance of aggravating activities, symptomatic pain management, and a rehabilitation
program. Symptomatic treatment can involve a number of
modalities, including the use of local treatment,
anti-inflammatory medication, and subacromial steroid
injections. Subacromial steroid injections are directed at
symptomatic control by decreasing the patients pain and
inflammation in the subacromial space. However, although
some of the components of impingement syndrome are
inflammatory in nature (ie, subacromial bursitis), others are
not (ie, rotator cuff tendinopathy).13
Current data on the long-term benefit of subacromial
steroid injections in the treatment of impingement
syndrome are contradictory.1,3 The purpose of this investigation was not to evaluate the efficacy of subacromial
steroid injections but to evaluate the temporal outcomes of
a nonoperative treatment protocol for the treatment of
impingement syndrome. Regardless of the long-term efficacy of subacromial steroid injections, the findings from
this investigation demonstrate significant improvement in
short-term outcomes after a subacromial steroid/lidocaine
injection. Specifically, patients levels of pain decreased on
average 44%, from a pain score of 4.8  1.9 to a score of
2.7  2.1 (P < .0001) after a subacromial steroid/lidocaine
injection. The results from this study also demonstrate that
a patients response to a subacromial injection may predict
his or her ultimate outcome. Those who had a poor
response to a subacromial steroid/lidocaine injection were
more likely to undergo surgical management. At 6 weeks
after an injection, 63% of patients undergoing arthroscopy
had a pain score greater than 5 of 10; in contrast, only 5%
of those patients who did not undergo shoulder surgery had
a pain score greater than 5.
Reports on the nonoperative treatment of impingement
syndrome have historically resulted in good to excellent
results in most patients.1,2,3,10 Unfortunately, little information is available on the temporal outcomes of patients
diagnosed with this disorder. The current investigation
evaluated patients at consistent time points after the initiation of nonoperative treatment that consisted of a subacromial steroid/lidocaine injection, followed by
a standardized physical therapy program. The results
demonstrate significant improvement over time in pain
scores, ASES scores, and the ability to perform activities of
daily living. These improvements continued up to 1 year,
with no improvement identified beyond that.
In this investigation, 20 patients (21%) underwent
surgical treatment; whereas 74 (79%) did not require
surgery. A segment of patients, however, continued to
report persistent shoulder pain and dysfunction despite not
undergoing surgery. Specifically, 22 patients (23%) had
persistent shoulder pain, with pain scores ranging from 1

177
to 4 of 10. Only 52 patients (55%) at the final evaluation
had not required shoulder surgery and reported their level
of pain as zero. This information suggests that although
many patients will improve with nonoperative management
of impingement syndrome, nearly half will require surgical
management or continue to have low-grade shoulder
pain.
In conclusion, this investigation showed a standardized
nonoperative treatment program for impingement syndrome
resulted in significant improvement in shoulder pain and
function in most patients. Patients demonstrated temporal
improvements in pain scores and the ability to perform
activities of daily living up to the 1-year follow-up assessment, with no improvement identified beyond 1 year. Overall,
21% of went on to have surgery on the affected shoulder.
However, many patients who did not undergo surgery
continued to have a low-grade level of shoulder pain as long as
2 years from the onset of the study.

References
1. Alvarez CM, Litchfield R, Jackowski D, Griffin S, Kirkley A. A
prospective, double-blind, randomized clinical trial comparing
subacromial injection of betamethasone and xylocaine to xylocaine
alone in chronic rotator cuff tendinosis. Am J Sports Med 2004;33:
255-62.
2. Bigliani L, Levine W. Subacromial Impingement Syndrome. J Bone
Joint Surg Am 1997;79:1854-68.
3. Blair B, Rokito AS, Cuomo F, Jarolem K, Zucherman JD. Efficacy of
injections of corticosteroids for subacromial impingement syndrome.
J Bone Joint Surg Am 1996;78:1685-9.
4. Codman EA, Akerson IB. The pathology associated with rupture of
the supraspinatus tendon. Ann Surg 1931;93:348-59.
5. Hawkins RJ, Brock RM, Abrams JS, Hobeika P. Acromioplasty for
impingement with an intact Rotator cuff. J Bone Joint Surg Br 1988;
70:795-7.
6. Neer CS. Impingement lesions. Clin Orthop Rel Res 1983;173:70-7.
7. Neer CS II. Anterior acromioplasty for the chronic impingement
syndrome in the shoulder: a preliminary report. J Bone joint Surg Am
1972;54:41-50.
8. MacDonald PB, Clark P, Sutherland K. An analysis of the diagnostic
accuracy of the Hawkins and Neer subacromial impingement signs.
J Shoulder Elbow Surg 2000;9:299-301.
9. Mohtadi NG, Vellet AD, Clark ML, et al. A prospective double-blind
comparison of magnetic resonance imaging and arthroscopy in the
evaluation of patients presenting with shoulder pain. J Shoulder Elbow
Surg 2004;13:258-65.
10. Morrison DS, Frogameni AD, Woodworth P. Non-operative treatment
of subacromial impingement syndrome. J Bone Joint Surg Am 1997;
79:732-7.
11. Richards RR, An KN, Bigliani LU, et al. A standardized method for
the assessment of shoulder function. J Shoulder Elbow Surg 1994;3:
347-52.
12. van derWindt DA, Koes BW, de Jong BA, Bouter LM. Shoulder
disorders in general practice: incidence, patient characteristics, and
management. Ann Rheum Dis 1995;54:959-64.
13. Yuan J, Murrell GA, Wei AQ, Wang MX. Apoptosis in rotator cuff
tendinopathy. J Orthop Res 2002;20:1372-9.