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PubMed1994

Ultrasound evaluation of painful rheumatoid shoulders.

OBJECTIVE: To provide more information about various types of rheumatoid involvement of the painful shoulder by ultrasonography (US). METHODS: US examinations were performed in 44 patients (88 shoulders) with rheumatoid arthritis (RA). The technique of shoulder ultrasonography was standardized in studies of 30 healthy volunteers (60 shoulders) without shoulder complaints. US findings were compared with clinical, laboratory and radiographic data to find any relationship. RESULTS: Sonography could reveal inflammatory conditions at early stages of RA when no radiographic changes were seen. The most common US finding was subacromial-subdeltoid bursitis in 61 shoulders (69%) of 35 patients. Synovitis in the glenohumeral joint was seen in 51 shoulders (58%) of 32 patients, biceps tendinitis in 50 shoulders (57%) of 29 patients and changes in the supraspinatus tendon in 29 shoulders (33%) of 20 patients. There were multiple rheumatoid symptoms in 61 shoulders (69%), one condition resulted in changes in 17 shoulders (19%) and no visible US findings in 10 shoulders (11%). Clinical findings were rather unspecific. Flexion, abduction and outward rotation were often restricted in shoulder symptoms, whereas inward rotation was rarely limited. Shoulder swelling indicated subacromial-subdeltoid bursitis. CONCLUSION: Ultrasonography is a very useful method for rheumatologists and orthopedists to see inside joints. It can provide remarkable help for local injection therapy and for planning surgery because of its suitability for evaluation of the extent of rheumatoid disease.

Adolescent↗
PubMed2005

Clinical Measures of Shoulder Mobility in the Professional Baseball Player.

Context: Professional baseball players must achieve a delicate balance between shoulder mobility and stability to attain optimal sports performance. The sport-specific demands of repetitive overhead throwing may result in an altered mobility-stability relationship.Objective: To evaluate clinical measures of shoulder mobility in professional baseball players in order to examine differences between the throwing and the nonthrowing shoulders and to describe chronic adaptations to throwing.Design: Descriptive.Setting: The athletic training room at Maryvale Baseball Park, Phoenix, AZ.Patients or Other Participants: Twenty-seven professional baseball players (20 pitchers, 7 position players; age = 20 +/- 1.6 years, height = 190.5 +/- 4.8 cm, mass = 91.6 +/- 9.6 kg) with no previous history of shoulder or elbow injury.Main Outcome Measure(s): We recorded scapular upward rotation at 4 levels of humeral elevation in the scapular plane (rest, 60 degrees , 90 degrees , 120 degrees ); posterior shoulder tightness; and passive, isolated glenohumeral joint internal and external range of motion.Results: Scapular upward rotation was significantly greater in the throwing shoulder (14.2 +/- 6.5 degrees ) than in the nonthrowing shoulder (10.6 +/- 6.1 degrees ) at 90 degrees of humeral elevation (P = .04). We observed no statistically significant difference in posterior shoulder tightness between the throwing (30.2 +/- 4.6 cm) and the nonthrowing (28.0 +/- 4.8 cm) shoulder (P = .09). In addition, the throwing shoulder exhibited a statistically significant decrease in isolated glenohumeral internal rotation (56.6 +/- 12.5 degrees ) compared with the nonthrowing shoulder (68.6 +/- 12.6 degrees ) (P = .001), with a concomitant increase in isolated glenohumeral external rotation (throwing = 108.9 +/- 9.0 degrees , nonthrowing = 101.9 +/- 5.9 degrees , P = .0014). An analysis of the total arc of motion (internal rotation + external rotation) revealed no statistically significant difference between sides (P = .15).Conclusions: The throwing shoulder exhibited significant differences in scapular and glenohumeral mobility compared with the nonthrowing shoulder. Further research is necessary to determine the relation of these adaptive changes, if any, to shoulder injury and disability.

Journal Article↗
PubMed2001

Dynamic MR imaging and stress testing in glenohumeral instability: comparison with normal shoulders and clinical/surgical findings.

Our objectives were to test the hypotheses that: 1) during shoulder motion, glenohumeral alignment differs between asymptomatic shoulders and those with symptomatic instability; 2) during magnetic resonance (MR)-monitored physical exam or stress testing, glenohumeral alignment differs between asymptomatic shoulders and those with instability; and 3) glenohumeral translation during MR stress testing correlates with findings of shoulder instability by clinical exam and exam under anesthesia (EUA). Using an open-configuration 0.5 T MR imaging (MRI) system, we studied symptomatic shoulders in 11 subjects and compared them to their contralateral asymptomatic shoulders. Each shoulder was studied during abduction/adduction and internal/external rotation to determine the humeral head position on the glenoid. An examiner also performed the MR stress test on each shoulder by applying manual force on the humeral head during imaging. All shoulders were assigned an instability grade from the MR stress test, and this grade was correlated with: 1) clinical exam grade assigned during preoperative assessment by an orthopedic surgeon and 2) intraoperative instability grade by EUA immediately preceding arthroscopy. With dynamic abduction and internal/external rotation, the humeral head remained centered on the glenoid in 9 of 11 shoulders, but in two subjects there were dramatic demonstrations of subluxation. With stress testing, a trend toward more joint laxity was demonstrated in symptomatic than in asymptomatic joints (P = 0.11). MR grading of instability correlated directly with clinical grading in six cases and underestimated the degree of instability relative to clinical exam in the other cases. MR instability grading systematically underestimated instability compared with EUA in 7 of the 10 cases that underwent surgical repair. We concluded that dynamic MR evaluation of glenohumeral alignment did not demonstrate abnormalities in symptomatic shoulders in 8 of 10 patients, whereas 2 patients showed dramatic findings of subluxation. Manual stress testing during dynamic MR examination showed a strong correlation with clinical instability grading. Dynamic shoulder MR examination during stress testing could, with further validation, become a useful adjunct to shoulder instability evaluations. J. Magn. Reson. Imaging 2001;13:748-756.

Adolescent↗
PubMed2004

Patterns of motion loss in subjects with idiopathic loss of shoulder range of motion.

BACKGROUND: Subjects with idiopathic loss of shoulder motion have difficulty sleeping, performing overhead activities, and completing activities of daily living. Treatment has been variable in approach and success. Cyriax's proposed shoulder capsular pattern was external rotation most limited followed by abduction followed by internal rotation. This investigation was performed to determine if a consistent pattern of motion loss was present in subjects with idiopathic loss of shoulder motion. METHODS: Repeated measurement of 25 (22 female) subjects' bilateral shoulder patterns of motion were compared. The three-dimensional position of the scapula and humerus throughout active shoulder abduction, external rotation, flexion, internal rotation, and scapular plane abduction was evaluated with an electromagnetic motion capture system. Patterns of motion loss were determined for both shoulders. The proportions of peak shoulder motion to mean maximum non-involved shoulders abduction, external, and internal rotation were utilized to determine the pattern of motion loss. FINDINGS: There was a significant difference in motion loss patterns between the involved and non-involved shoulders with the arm at the side. The internal rotation less than abduction less than external rotation pattern was demonstrated in 14 of 25 (56%) involved shoulders. No pattern was present in 14 of 21 (67%) non-involved shoulders. With the arm abducted, internal rotation was the most limited motion in 23 of 25 (92%) involved shoulders. INTERPRETATION: The results did not support Cyriax's proposed glenohumeral capsular pattern. Defining the pattern of motion loss in subjects with idiopathic loss of shoulder motion may assist in diagnosis and treatment.

Adult↗
PubMedDate not supplied

A finite element model of the shoulder: application to the comparison of normal and osteoarthritic joints.

OBJECTIVE: The objective of the present study was to develop a numerical model of the shoulder able to quantify the influence of the shape of the humeral head on the stress distribution in the scapula. The subsequent objective was to apply the model to the comparison of the biomechanics of a normal shoulder (free of pathologies) and an osteoarthritic shoulder presenting primary degenerative disease that changes its bone shape. DESIGN: Since the stability of the glenohumeral joint is mainly provided by soft tissues, the model includes the major rotator cuff muscles in addition to the bones. BACKGROUND: No existing numerical model of the shoulder is able to determine the modification of the stress distribution in the scapula due to a change of the shape of the humeral head or to a modification of the glenoid contact shape and orientation. METHODS: The finite element method was used. The model includes the three-dimensional computed tomography-reconstructed bone geometry and three-dimensional rotator cuff muscles. Large sliding contacts between the reconstructed muscles and the bone surfaces, which provide the joint stability, were considered. A non-homogenous constitutive law was used for the bone as well as non-linear hyperelastic laws for the muscles and for the cartilage. Muscles were considered as passive structures. Internal and external rotations of the shoulders were achieved by a displacement of the muscle active during the specific rotation (subscapularis for internal and infrapinatus for external rotation). RESULTS: The numerical model proposed is able to describe the biomechanics of the shoulder during rotations. The comparison of normal vs. osteoarthritic joints showed a posterior subluxation of the humeral head during external rotation for the osteoarthritic shoulder but no subluxation for the normal shoulder. This leads to important von Mises stress in the posterior part of the glenoid region of the pathologic shoulder while the stress distribution in the normal shoulder is fairly homogeneous. CONCLUSION: This study shows that the posterior subluxation observed in clinical situations for osteoarthritic shoulders may also be cause by the altered geometry of the pathological shoulder and not only by a rigidification of the subscapularis muscle as often postulated. This result is only possible with a model including the soft tissues provided stability of the shoulder. RELEVANCE: One possible cause of the glenoid loosening is the eccentric loading of the glenoid component due to the translation of the humeral head. The proposed model would be a useful tool for designing new shapes for a humeral head prosthesis that optimizes the glenoid loading, the bone stress around the implant, and the bone/implant micromotions in a way that limits the risks of loosening.

Computer Simulation↗
PubMed2000

Secondary impingement in the shoulder. An improved terminology in impingement.

Non-traumatic shoulder pain in the overhead athlete is a diagnostic challenge. In the last decade shoulder arthroscopy and magnetic resonance imaging (MRI) techniques have extended our knowledge. Previously unknown pathologic changes in the glenohumeral joint have been demonstrated and it is recognized that impingement symptoms and instability are often related. Shoulder dysfunction in overhead athletes may be caused by shoulder instability. However, a possible instability in the shoulder is often "silent" and difficult to demonstrate by ordinary tests and has therefore by some been termed "functional instability". It is now thought that functional instability in the shoulder may lead to a vicious cycle involving microtraumata and attenuation of the capsular complex, and may eventually lead to shoulder pain. Changes in shoulder proprioception, measured by testing kinaesthetic sense and position sense, can be related to different pathologic changes in the shoulder, and sensory motor control may be an important factor for functional stability in the shoulder. MRI and arthroscopical findings in athletes with shoulder pain are changes in the glenoid labrum, the humeral head, the rotator cuff, biceps tendon and the capsular complex. However, these findings often present other clinical entities than impingement and are not always associated with instability. Clinically, there are tests that can objectively distinguish some of the pathological findings. However, we need more exact methods to further improve our clinical diagnoses of the painful shoulder. One of the keys could be an extended knowledge about the pathophysiology behind functional instability. This review focuses on an improved terminology in impingement based on the current knowledge of impingement and instability in the shoulder.

Adult↗
PubMedDate not supplied

Characteristics of unsatisfactory shoulder arthroplasties.

Failure of shoulder arthroplasty is often defined as a complication or the need for revision, but it may also be viewed as a result that does not meet the expectations of the patient. To enhance our understanding of failed shoulder arthroplasties, we identified the characteristics common to a series of 139 consecutive patients who came to our shoulder consultation service because of dissatisfaction with the result of their shoulder arthroplasty. Primary osteoarthritis (28%) and proximal humeral fractures (26%) were the most common indications for the initial arthroplasty. Seventy-three shoulders (fifty-two percent) had at least one surgery before arthroplasty was performed. Seventy-four percent of the shoulders were stiff, 35% were unstable, and in the total shoulders, 59% of the glenoids were loose. Components were substantially malpositioned in 23%. Forty-two percent of shoulders with a failed hemiarthroplasty had substantial glenoid erosion, and 43% of shoulders that had undergone a hemiarthroplasty for fracture had nonunion of the tuberosities. Patients demonstrated impaired shoulder function; on average, they could perform only 2 of 12 shoulder functions. The rate of revision underestimated the rate of failure, as 23% of arthroplasties did not undergo revision. The challenge of achieving patient satisfaction after arthroplasty may be greater than previously recognized. Many of these unsatisfactory shoulder arthroplasties did not meet the criteria for failure used in previously published series. These observations suggest that greater attention to achieving proper component position, postoperative motion, and in fracture cases, fixation of the tuberosities may lead to increased patient satisfaction after shoulder arthroplasty.

Aged↗
PubMed2005

Traumatic shoulder dislocation in the adolescent athlete: advances in surgical treatment.

PURPOSE OF REVIEW: The shoulder joint has the greatest range of motion of any joint in the body and as a result is particularly susceptible to dislocation and subluxation. Recurrent instability is a common complication after traumatic shoulder dislocation in young people, with rates as high as 100% in skeletally immature patients and 96% in for adolescents. Treatment for shoulder dislocation has traditionally involved immobilization followed by a rehabilitation program. Recent studies have reported decreased rates of recurrent instability and improved outcomes in patients treated with surgical stabilization of acute, traumatic shoulder dislocation. The purpose of this review is to review recent publications concerning the treatment of traumatic shoulder dislocations in adolescents. RECENT FINDINGS: Lawton et al. retrospectively reviewed 70 shoulders in 66 patients 16 years old or younger treated for shoulder instability with follow-up more than 2 years. Forty-two shoulders were successfully treated with physical therapy, whereas 28 eventually required surgery. Subsequently, Deitch et al. retrospectively identified 32 patients between 11 and 18 years of age with radiographically documented traumatic anterior shoulder dislocation. Instability recurred in 75% of patients and 50% eventually required surgical stabilization. Bottoni et al. reported results of a prospective randomized trial comparing arthroscopic stabilization to nonoperative treatment of acute, traumatic shoulder dislocations in patients aged 18 to 26 years. Recurrent instability developed in 75% of patients treated conservatively versus 11% in those treated with surgery. DeBerardino et al. prospectively evaluated arthroscopic stabilization of acute shoulder dislocations in 48 young athletes with an average follow-up of 37 months and reported a 12% rate of recurrent instability. All patients with stable shoulders were able to return to their previous levels of activity. SUMMARY: Conservative management of traumatic shoulder dislocations in young patients is associated with high rates of recurrent instability. Recent studies have demonstrated improved results and significant reduction in recurrent instability in patients treated with surgical stabilization when compared with nonoperative treatment.

Adolescent↗
PubMed2004

A comparison of four shoulder-specific questionnaires in primary care.

OBJECTIVES: To compare the validity, responsiveness to change, and user friendliness of four self completed, shoulder-specific questionnaires in primary care. METHODS: A cross sectional assessment of validity and a longitudinal assessment of responsiveness to change of four shoulder questionnaires was carried out: the Dutch Shoulder Disability Questionnaire (SDQ-NL); the United Kingdom Shoulder Disability Questionnaire (SDQ-UK); and two American instruments, the Shoulder Pain and Disability Index (SPADI) and the Shoulder Rating Questionnaire (SRQ). 180 primary care consulters with new shoulder region pain each completed two of the questionnaires, as well as EuroQoL and 10 cm visual analogue scales (VAS) for overall pain and difficulty due to the shoulder problem. Each participant was assessed by a standardised clinical schedule. Postal follow up at 6 weeks included baseline measures and self rated assessment of global change of the shoulder problem (seven point Likert scale). RESULTS: Strongest correlations were found for SDQ-UK with EuroQoL 5 score, and for SPADI and SRQ with shoulder pain and difficulty VAS. All shoulder questionnaires correlated poorly with active movement at the painful shoulder. SPADI and SRQ performed better on ROC analysis than SDQ-NL and SDQ-UK (areas under the curve of 0.87, 0.85, 0.77, and 0.77, respectively). However, SRQ scores changed significantly over time in stable subjects. CONCLUSIONS: Cross sectional comparison of the four shoulder questionnaires showed they had similar overall validity and patient acceptability. SPADI and SRQ were most responsive to change. Additionally, SPADI was the quickest to complete and scores did not change significantly in stable subjects.

Adult↗
PubMed2000

Sonographic features of dialysis-related amyloidosis of the shoulder.

This study evaluated the diagnostic role of ultrasonography in dialysis-related amyloidosis in shoulders of chronically hemodialyzed patients. Fourteen shoulders of 12 long-term hemodialysis patients were examined. All patients had been on dialysis for at least 10 years. All patients had varying degrees of pain and limitations of movement in the studied shoulders. Dialysis-related amyloidosis was the presumed diagnosis in all patients. Any patient with a history of any disease, other than dialysis-related amyloidosis, capable of producing a pathologic shoulder condition was excluded. The following parameters were studied: supraspinatus and biceps tendon thickness, tendon tears, synovial thickening, and the presence of hypoechoic material around tendons and within bursae. All shoulders had a nonhomogeneous thickening, greater than 7 mm, of the supraspinatus tendon. Seven shoulders (50%) had abnormal thickening of the biceps tendon (4 mm or greater), and two shoulders had abnormal thickening of the subscapularis tendon. Hypoechoic deposits were seen in the subdeltoid bursae and biceps sheaths in five and six shoulders, respectively. Three shoulders showed partial tears of the supraspinatus tendon, one shoulder showed a tear in the biceps tendon, and one shoulder had a tear in the subscapularis tendon. Ultrasonography is an excellent imaging modality in diagnosing the presence of dialysis-related amyloidosis in symptomatic shoulders of long-term hemodialysis patients, without having to resort to invasive procedures. The results of previous studies have been confirmed and new ultrasonographic findings described. Of particular interest is the involvement of the subscapularis tendon in dialysis-related amyloidosis. Repeat ultrasonography can become an important way to follow-up progression of shoulder dialysis-related amyloidosis in hemodialyzed patients.

Adult↗
PubMed2003

The effects of various therapeutic measures on shoulder strength and muscle soreness after baseball pitching.

AIM: This study was intended as an investigation of the effects of various therapeutic measures on the shoulder strength and muscle soreness after baseball pitching. METHODS EXPERIMENTAL DESIGN: participants threw 98 pitches in a simulated single game. The mode of the therapeutic measures after pitching were classified into 4 groups; the control group (CON), the ice treatment group (IT), the light shoulder exercise group (LSE) and the ice treatment with LSE group (ILSE). Each therapeutic measure was applied to the dominant shoulder immediately after pitching. PARTICIPANTS: 7 healthy, skilled baseball pitchers. MEASURES: both shoulder strength and muscle soreness were measured before pitching, immediately after pitching (Post-P), at the time of the therapeutic measure (Post-TM), and 24 hours after pitching (Post-24 h). RESULTS: All 4 groups showed shoulder strength losses in shoulder abduction, internal/external rotation with no shoulder abduction or with the shoulder abducted to 90 degrees immediately after pitching. ILSE had greater recovery from Post-P values at Post-TM or Post-24 h than the other methods in all 5 shoulder strengths. On the other hand, the soreness in shoulder internal rotation was increased significantly from Post-P and continued by Post-24 h. Both IT and ILSE had beneficial effects on reducing the shoulder muscle soreness at Post-TM or Post-24 h. CONCLUSION: The findings of this study suggested that ILSE was the optimal therapeutic measure against decreased shoulder strength or increased shoulder muscle soreness resulting from the repetitive baseball pitching.

Adult↗
PubMed2003

[Shoulder arthroplasty for osteoarthritis after prior surgery for anterior instability: a report of 27 cases].

PURPOSE OF THE STUDY: The purpose of this study was to analyze the natural history of shoulder osteoarthritis secondary to prior surgery for anterior instability, to evaluate clinical and radiological results of shoulder prosthesis, and to compare results with reports in the literature. MATERIAL AND METHODS: Twenty-seven shoulder prostheses (Aequalis) were implanted in patients with osteoarthritis of the shoulder after prior instability surgery. These shoulders were reviewed retrospectively at a mean follow-up of 46 months (range 24-48). Prior surgery had been performed with coracoid block in two-thirds of the shoulders and with soft-tissue procedures in one-third. Twenty-four shoulders had had one instability procedure, several procedures had been performed in three. The Constant score was used to assess clinical status preoperatively and at last follow-up. Male gender predominated (16/27), and mean age at first dislocation was 31.6 years (4 patients experienced their first dislocation after the age of 60 years). The patients had a mean 18.2 dislocations. The natural history of osteoarthritis was long: 24.2 years on the average. Mean age at arthroplasty was 55.8 years. The preoperative images demonstrated an iatrogenic factor in 5 shoulders and constructive osteoarthitis in 24. Posterior glenoid wear was observed in 24% of the cases, fatty degeneration of the subscapularis in 45% and full-thickness tears of the supraspinatus in 4 cases. The anterior scar tissue was released and implants were positioned anatomically in 26 cases. Total arthroplasty was used for 21 shoulders and a humeral prosthesis for 6. RESULTS: There were five complications including three anterior prosthetic instability, all three in patients who were over 60 years of age at their first instability surgery (one of these three patients required revision arthroplasty). Outcome was good or excellent in 56% of the shoulder with a mean weighted Constant score of 83%: mean gain in pain score=8.3 points, in anterior elevation=51 degrees, in external rotation=33.5 degrees. The type of prior instability surgery and preoperative active external rotation had no determining effect on outcome. Factors correlated significantly with outcome were fatty degeneration of the rotator cuff muscles, particularly the subscapularis. DISCUSSION: Osteoarthritis of the shoulder has a long natural history, 26 years in our patients excepting those whose first dislocation occurred after the age of 60 years. Posterior glenoid wear, described by others, was only found in 24% of the shoulders in this series. Surgical dissection and release of anterior scar tissue was difficult. The overall results of arthroplasty were good and were correlated with fatty degeneration of the rotator cuff muscles, particularly the subscapularis, but not with the type of instability surgery. These results were less satisfactory than reported in series of arthroplasty for primary centred osteoarthritis: complications occurred in 18% of the shoulders with three cases of anterior dislocation. Unlike reports of arthroplasty after instability surgery where many of the patients had several operations, overall results in our series were not compromised by a large number of multiple interventions.

Adolescent↗
PubMed1999

[Current status and perspectives of shoulder replacement].

Basis of the modern shoulder implants is the Neer II-system, a non constrained total shoulder prosthesis with conforming radii of curvature and improved protection against dislocation. The second generation of shoulder prosthesis is based on the geometric shaft design of the Neer II prosthesis and offers not only a variety of modular head- and shaft-sizes but also through different radii a physiologic rotation-translation-mechanism. The third generation of humeral head prosthesis carries the concept of an anatomic reconstruction one step further and enables the surgeon to adjust the inclination and the eccentric offset of the humeral head to restore the centre of rotation. The latest development in shoulder arthroplasty are humeral head prosthesis with a fully variable 3-dimensional modularity to independently adjust the prosthetic head position regardless of the individual shaft geometry. This achieves a 3-dimensional adaptability of the prosthetic head about the stem axis in the coronary and in the sagittal plane. Besides of the humeral shaft prosthesis an alternative concept of shoulder joint replacement is established - the replacement of the humeral head articular surface. A hemispheric surface prosthesis - cup arthroplasty - is cemented onto the residual humeral head, which eliminates the obligatory humeral head resection and the reaming of the medullary canal. Bipolar shoulder prosthesis are humeral shaft prosthesis with a bi-rotational head system. Their indication is limited to pre-existing lesions of the rotator cuff and/or the glenoid surface. The inverse total shoulder prosthesis reverses the articular surface morphology of the humeral head and the glenoid. The hemispheric glenoid component serves as the centre of rotation for the concave epiphyseal proximal humerus component. This implant is especially used in cases of massive rotator cuff deficiencies. The role of shoulder prosthesis in treating acute humeral head fractures needs special consideration. A fracture prosthesis has to restore the exact length of the humerus, the centre of rotation, and the anatomical retroversion. Positioning of the tubercula and their adequate osteosynthesis is most critical and fundamental to ensure a correct healing process. A failed consolidation of the tubercula does not lead to a satisfying result. The shoulder joint replacement can be sufficiently fixated in cemented, cementless or hybrid techniques. Today several component design variations of cemented glenoid implants exist. Their main distinction is the fixation system which can be divided into two main groups - the keel - and the peg-shaped glenoid components. The peg-shaped anchorage system shall guarantee a greater stability against shear-forces. Cementless glenoid components consist of a polyethylene inlay and a surface treated metal-back with an integrated fixation system. These fixation systems are object of intensive biomechanical research and range from conventional screw fixation to specialised cone systems and self-cutting cage-screw-systems. The critical area of cementless glenoid components is the transition zone of the PE-inlay and the metal-back because of high force development. The question of implanting a hemi- or total shoulder prosthesis is answered by the morphologic changes of the glenoid articular surface, which includes the size of the subchondral defect and the underlying etiology of the shoulder joint disease, and the age of the patient. Preoperative planning must consist of an adequate radiologic work-up - X-ray, CT or MRI - to accurately assess the glenoid morphology. G. Walch categorised the different glenoid lesions and developed a very important classification of possible glenoid deformations. To compare and evaluate the operative results one must consider the different shoulder prosthesis and the discrepancies between a hemi- and a total shoulder prosthetic replacement. Looking at the loosening and survival rate of the implant the results are

Equipment Failure Analysis↗
PubMed2001

General coordination of shoulder, elbow and wrist dynamics during multijoint arm movements.

Studies of multijoint arm movements have demonstrated that the nervous system anticipates and plans for the mechanical effects that arise from motion of the linked limb segments. The general rules by which the nervous system selects appropriate muscle activities and torques to best deal with these intersegmental effects are largely unknown. In order to reveal possible rules, this study examined the relationship of muscle and interaction torques to joint acceleration at the shoulder, elbow and wrist during point-to-point arm movements to a range of targets in the horizontal plane. Results showed that, in general, dynamics differed between the joints. For most movements, shoulder muscle torque primarily determined net torque and joint acceleration, while interaction torque was minimal. In contrast, elbow and wrist net torque were determined by a combination of muscle and interaction torque that varied systematically with target direction and joint excursion. This "shoulder-centered pattern" occurred whether subjects reached targets using straight or curved finger paths. The prevalence of a shoulder-centered pattern extends findings from a range of arm movement studies including movement of healthy adults, neurological patients, and simulations with altered interaction effects. The shoulder-centered pattern occurred for most but not all movements. The majority of the remaining movements displayed an "elbow-centered pattern," in which muscle torque determined initial acceleration at the elbow and not at the shoulder. This occurred for movements when shoulder excursion was <50% of elbow excursion. Thus, both shoulder- and elbow-centered movements displayed a difference between joints but with reversed dynamics. Overall, these findings suggest that a difference in dynamics between joints is a general feature of horizontal plane arm movements, and this difference is most commonly reflected in a shoulder-centered pattern. This feature fits well with other general shoulder-elbow differences suggested in the literature on arm movements, namely that: (a) agonist muscle activity appears more closely related to certain joint kinematics at the shoulder than at the elbow, (b) adults with neurological damage display less disruption of shoulder motion than elbow motion, and (c) infants display adult-like motion first in the shoulder and last at the wrist.

Adult↗
PubMed1995

An objective definition of shoulder dystocia: prolonged head-to-body delivery intervals and/or the use of ancillary obstetric maneuvers.

OBJECTIVE: To generate an objective definition of shoulder dystocia by timing the events of the second and third stages of labor, and to define the true incidence of shoulder dystocia. METHODS: In 34 arbitrarily selected 24-hour time periods, a nonparticipating observer prospectively timed intervals of the second stage of labor in all vaginal deliveries and recorded the use of obstetric maneuvers (McRoberts, episiotomy after delivery of the fetal head, intentional extension of initial episiotomy after delivery of the fetal head, suprapubic pressure, posterior arm rotation to an oblique angle, rotation of the infant by 180 degrees, delivery of the posterior arm, and general anesthesia) and whether the obstetric attendant identified a delivery with shoulder dystocia. All data are reported as mean +/- standard error of the mean. RESULTS: Two hundred fifty deliveries were timed and recorded prospectively. Mean intervals (in seconds) in nonmaneuver patients were as follows: head to anterior shoulder 14.8 +/- 1.0, anterior to posterior shoulder 3.9 +/- 0.6, posterior shoulder to body 5.4 +/- 0.8, and total head-to-body time 24.2 +/- 1.3. Three groups of patients were defined after delivery. The maneuver group consisted of 27 patients requiring any of the aforementioned obstetric maneuvers, although the obstetric attendant identified only 16 of these as shoulder dystocia. The prolonged delivery group included 29 patients with the head-to-body delivery interval exceeding the mean plus two standard deviations (60 seconds) of nonmaneuver patients. Sixteen of the 27 maneuver patients were identified as prolonged. The 210 not identified as maneuver or prolonged were considered to be normal. Normal patients had a significantly lower newborn birth weight (3269 +/- 38 g), and a lower proportion of 1-minute Apgar scores of 7 or less (11%) than did the maneuver (4247 +/- 86 g, 41%) and prolonged groups (3952 +/- 118 g, 34%). Defining shoulder dystocia as a prolonged head-to-body delivery time and/or the use of obstetric maneuvers identified 40 patients who had birth weights and 1-minute Apgar scores significantly different from the normal patients. CONCLUSION: The incidence of shoulder dystocia, as defined by the use of ancillary obstetric maneuvers, is higher than that reported previously, and the reporting of shoulder dystocia appears to be unreliable. The interval from head-to-body delivery is delayed significantly in patients with shoulder dystocia, despite the lack of recognition of shoulder dystocia. We propose defining shoulder dystocia as a prolonged head-to-body delivery time (eg, more than 60 seconds) or the need for ancillary obstetric maneuvers.

Adult↗
PubMed2004

Shoulder pain and its consequences in paraplegic spinal cord-injured, wheelchair users.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To describe the consequences of shoulder pain on activity and participation in spinal cord-injured paraplegic wheelchair users. To describe the prevalence and type of shoulder pain. SETTING: Two spinal cord injury (SCI) centres in Sweden. METHODS: All subjects with paraplegia due to an SCI of more than 1 year living in the counties of Uppsala and Linköping, Sweden were contacted by mail and asked to fill in a questionnaire (89 subjects). Those of the responding 56 subjects with current shoulder pain were asked to participate in further examination and interviews. A physiotherapist examined 13 subjects with shoulder pain in order to describe type and site of impairment. To describe consequences of shoulder pain on activity and participation, the Constant Murley Scale (CMS), the Wheelchair Users Shoulder Pain Index (WUSPI) the Klein & Bell adl-index and the Canadian Occupational Performance Measure (COPM) were used. RESULTS: Out of all respondents, 21 had shoulder pain (37.5%). Data from 13 of those subjects were used in the description of type and consequences of shoulder pain. Findings of muscular atrophy, pain, impingement and tendinits were described. We found no difference in ADL-performance with, respectively without, shoulder pain (P=0.08) using the Klein & Bell adl-index. No correlation was found between the various descriptions of impairment, activity limitations and participation restriction (P>0.08). All together 52 problems with occupational performance due to shoulder pain were identified using the COPM. Of these, 54% were related to self-care activities. CONCLUSION: The consequences of shoulder pain in paraplegic wheelchair users are mostly related to wheelchair activities. Since the wheelchair use itself presumably cause shoulder problems, this will become a vicious circle. More research is needed in order to reduce shoulder problems in wheelchair users.

Adult↗
PubMed2003

Mechanical and psychosocial factors predict new onset shoulder pain: a prospective cohort study of newly employed workers.

AIM: To test the hypothesis that work related mechanical and psychosocial factors predict new onset shoulder pain in newly employed workers. METHODS: Two year prospective study of newly employed workers from 12 diverse occupational settings. At baseline, 1081 subjects provided information on work related mechanical and psychosocial risk factors, and current pain status. RESULTS: In all, 803 (74%) subjects were free from shoulder pain at baseline. Of those, 638 (79%) responded at 12 months and 476 (88%) at 24 months. New onset shoulder pain was reported by 93 (15%) and 73 (15%) subjects respectively. An increased risk of symptom onset was found in subjects reporting mechanical exposures involving heavy weights including lifting with one or two hands, carrying on one shoulder, lifting at or above shoulder level, and pushing or pulling. Working with hands above shoulder level was also predictive of new onset shoulder pain. Of the psychosocial factors examined, the strongest predictor was monotonous work. Those individuals with any other previous pain also had an increased risk of new onset shoulder pain at follow up. In multivariate analysis, lifting heavy weights with one or two hands, pushing or pulling heavy weights, working with hands above shoulder level, and monotonous work were independently associated with new onset shoulder pain. CONCLUSIONS: This study supports the hypothesised relation between mechanical risk factors and shoulder pain. In general, work related psychosocial factors were modestly associated with new onset shoulder pain. However, monotonous work was a strong risk factor for new onset shoulder pain.

Adult↗
PubMed2007

A randomized controlled study of botulinum toxin A in the treatment of hemiplegic shoulder pain associated with spasticity.

OBJECTIVES: To assess the effects of botulinum toxin A (BT-A) on hemiplegic shoulder pain associated with spasticity. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: Outpatient clinic of a rehabilitation department. PARTICIPANTS: Patients, more than three months post stroke, with hemiplegic shoulder pain associated with shoulder adductor and elbow flexor spasticity, randomly assigned to BT-A or placebo. INTERVENTION: One-time injection of BT-A (500 units) into the pectoralis major and biceps brachii on the hemiplegic side. MAIN MEASURES: Visual analogue scale of shoulder pain (0 -10), shoulder adductor and elbow flexor tone using the Ashworth Scale and passive range of shoulder abduction. These were assessed at baseline, four weeks, eight weeks and 12 weeks post injection. RESULTS: Seventeen patients were enrolled, eight in the BT-A group and nine in the placebo group. At baseline, the median visual analogue scale score for shoulder pain was 6, the median Ashworth Scale shoulder adductor and elbow flexor spasticity score was 2 and the median range of shoulder abduction 76 degrees. Subjects who received BT-A showed significantly greater improvements in median shoulder adductor and elbow flexor Ashworth Scale scores than placebo at week 4 (P B / 0.01) but not at week 8 and 12. For shoulder pain and passive shoulder abduction range, all subjects showed postinjection improvements and no difference could be demonstrated between the two groups. DISCUSSION: Possible reasons for the negative finding in this study include the small sample size and the presence of causes of shoulder pain not related to spasticity which could have confounded outcome.

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