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PubMed2005

Patient characteristics and clinical management of patients with shoulder pain in U.S. primary care settings: secondary data analysis of the National Ambulatory Medical Care Survey.

BACKGROUND: Although shoulder pain is a commonly encountered problem in primary care, there are few studies examining its presenting characteristics and clinical management in this setting. METHODS: We performed secondary data analysis of 692 office visits for shoulder pain collected through the National Ambulatory Medical Care Survey (Survey years 1993-2000). Information on demographic characteristics, history and place of injury, and clinical management (physician order of imaging, physiotherapy, and steroid intraarticular injection) were examined. RESULTS: Shoulder pain was associated with an injury in one third (33.2% (230/692)) of office visits in this population of US primary care physicians. Males, and younger adults (age < or = 52) more often associated their shoulder pain with previous injury, but there were no racial differences in injury status. Injury-related shoulder pain was related to work in over one-fifth (21.3% (43/202)) of visits. An x-ray was performed in 29.0% (164/566) of office visits, a finding that did not differ by gender, race, or by age status. Other imaging (CT scan, MRI, or ultrasound) was infrequently performed (6.5%, 37/566). Physiotherapy was ordered in 23.9% (135/566) of visits for shoulder pain. Younger adults and patients with a history of injury more often had physiotherapy ordered, but there was no significant difference in the ordering of physiotherapy by gender or race. Examination of the use of intraarticular injection was not possible with this data set. CONCLUSION: These data from the largest sample of patients with shoulder pain presenting to primary care settings offer insights into the presenting characteristics and clinical management of shoulder pain at the primary care level. The National Ambulatory Medical Care Survey is a useful resource for examining the clinical management of specific symptoms in U.S. primary care offices.

Adult↗

PubMed2006

A prediction rule for shoulder pain related sick leave: a prospective cohort study.

BACKGROUND: Shoulder pain is common in primary care, and has an unfavourable outcome in many patients. Information about predictors of shoulder pain related sick leave in workers is scarce and inconsistent. The objective was to develop a clinical prediction rule for calculating the risk of shoulder pain related sick leave for individual workers, during the 6 months following first consultation in general practice. METHODS: A prospective cohort study with 6 months follow-up was conducted among 350 workers with a new episode of shoulder pain. Potential predictors included the results of a physical examination, sociodemographic variables, disease characteristics (duration of symptoms, sick leave in the 2 months prior to consultation, pain intensity, disability, comorbidity), physical activity, physical work load, psychological factors, and the psychosocial work environment. The main outcome measure was sick leave during 6 months following first consultation in general practice. RESULTS: Response rate to the follow-up questionnaire at 6 months was 85%. During the 6 months after first consultation 30% (89/298) of the workers reported sick leave. 16% (47) reported 10 days sick leave or more. Sick leave during this period was predicted in a multivariable model by a longer duration of sick leave prior to consultation, more shoulder pain, a perceived cause of strain or overuse during regular activities, and co-existing psychological complaints. The discriminative ability of the prediction model was satisfactory with an area under the curve of 0.70 (95% CI 0.64-0.76). CONCLUSION: Although 30% of all workers with shoulder pain reported sick leave during follow-up, the duration of sick leave was limited to a few days in most workers. We developed a prediction rule and a score chart that can be used by general practitioners and occupational health care providers to calculate the absolute risk of sick leave in individual workers with shoulder pain, which may help to identify workers who need additional attention. The performance and applicability of our model needs to be tested in other working populations with shoulder pain to enable valid and reliable use of the score chart in everyday practice.

Disability Evaluation↗

PubMed2000

The lax shoulder in females. Issues, answers, but many more questions.

A review of the existing data on shoulder laxity in females reveals there are insufficient data to confirm the commonly held belief that shoulders in females are more lax than shoulders in males. Laxity is not synonymous with instability. Although females may have increased generalized joint laxity relative to males, generalized joint laxity does not correlate with shoulder laxity. There is conflicting data regarding shoulder laxity and gender. A review of patients with multidirectional instability who were treated operatively showed that 55% of the patients were female (N = 94) and 45% were male (N = 77), but the number or gender of patients who were treated nonoperatively was not reported. Multidirectional instability is reviewed in the context of the lax shoulder in the female. Initial treatment should be nonoperative, emphasizing physical therapy and dynamic stabilization of the shoulder. If nonoperative treatment fails, open or arthroscopic inferior capsular shift stabilization is recommended. Additional basic science and clinical trials are needed to determine whether thermal capsulorrhaphy should be considered in the treatment of patients with multidirectional instability of the shoulder.

Athletic Injuries↗

PubMed1984

Arthrographic studies in painful hemiplegic shoulders.

The rehabilitation of hemiplegic patients is often prolonged by the problem of painful shoulder. The specific etiology of this problem is controversial and treatment does not always produce the desired results. Thirty hemiplegic patients with painful, stiff ipsilateral shoulder joints were studied. The mean interval from the onset of stroke to the onset of painful shoulder was 3 months. On shoulder arthrography, 23 patients had capsular constriction typical of frozen shoulder (adhesive capsulitis). Seven patients had normal arthrograms. None showed rotator cuff or capsular tears. Electromyography revealed electrical silence in the shoulder musculature at rest. These findings indicate that the painful, stiff shoulder developing after hemiplegia is not caused by rotator cuff tear or by spasticity, but probably has a pathogenesis similar to that of idiopathic frozen shoulder.

Adult↗

PubMed1995

Anatomy and pathomechanics of shoulder instability.

The mechanisms contributing to glenohumeral stability are complex and varied. The rotator cuff is the dominant contributor to stability through the mid arcs of motion through concavity compression. At the end ranges of motion, the capsular ligamentous system becomes responsible for shoulder stability. As the shoulder position varies from adduction to abduction and internal to external rotation, varying components of the capsular ligamentous system become responsible for static shoulder stability. The nature of the individual ligament contribution to overall static stability has become better known through biomechanical cutting studies of cadaveric shoulders. Further insight into the pathoanatomy of shoulder instability can be gleaned from MR imaging studies that defined which tissues have been injured and which have not. This more detailed understanding of the capsular ligamentous system will eventually result in a more precise nomenclature of defining shoulder instability. The current use of the words anterior shoulder instability is not unlike the use of the term internal derangement of the knee from the late 1970s. In the future, there will be discussions of clinical diagnoses of IGHLC injury or incompetence. The more precisely we know all the details of the mechanisms of shoulder stability, the more precisely we can clinically define the various injuries and syndromes that afflict our patients.

Biomechanical Phenomena↗

PubMed1998

[Double oblique MR images of the shoulder: comparison with conventional images].

PURPOSE: Because the scapula is not only slanted on transverse sections but also inclines on sagittal section, we now perform shoulder MR imaging using double oblique images (DOI), which are planes perpendicular or parallel to the long axis of the scapula obtained with oblique sagittal scout imaging. The purpose of this study was to evaluate the usefulness of double oblique shoulder MR imaging. MATERIALS AND METHODS: MR images of shoulders with operatively or arthroscopically proven lesions (20 cases) that had been examined on both conventional images (CI) and DOI were retrospectively reviewed. DOI were compared with CI not only in terms of diagnostic performance but also in their ability to identify the details of shoulder anatomy. All MR studies were done with a shoulder coil on a high-field (1.5T) unit. RESULTS: Although the accuracy of DOI in diagnosing shoulder disorders such as rotator cuff tear and labrum injury was not as good as that of CI, DOI were better for identifying or discriminating muscles and tendons of the rotator cuff, labralbicipital junction and anterior band of the inferior gleno-humeral ligament, and for recognizing the correct position of the glenoid labrum. CONCLUSION: MR double oblique imaging of the shoulder provides more detailed information about shoulder anatomy and disorders than conventional imaging.

Adolescent↗

PubMedDate not supplied

Long-term functional results after manipulation of the frozen shoulder.

The use of shoulder manipulation in the treatment of frozen shoulder syndrome remains controversial. Opponents cite the risk of dislocation, fracture, nerve palsy, and rotator cuff tearing as limiting the usefulness of manipulation. A retrospective study of 38 shoulder manipulations in 32 patients was performed. These patients were followed for an average time of 58 months. The patients were examined in follow up for combined shoulder range of motion, external and internal rotation strength, and status of the long head of the biceps. Manipulation was performed in all patients by the senior author and supervised physical therapy was begun within 24 hours of the manipulation. The average recovery time was 13 weeks. In this series, 97% of patients had relief of pain and recovery of near complete range of motion, although 8% required a second manipulation to obtain a successful result. Mild weakness to manual muscle testing was present in 5.3% of patients in external rotation and 10.5% of patients in internal rotation. There was no deterioration of shoulder function with time. In fact, most patients improved with passage of time, even more. There was no evidence of biceps tendon rupture or rotator cuff insufficiency at the time of follow up in any of the patients. No fractures, dislocations or nerve palsies were observed, although one patient who had no premanipulation arthrogram was found to have a rotator cuff tear a few months after failed manipulation. Manipulation of the shoulder can therefore be offered to reduce the pain and period of disability in patients who fail conservative treatment of frozen shoulder syndrome.

Adult↗

PubMed2006

Intrapartum interventions for preventing shoulder dystocia.

BACKGROUND: The early management of shoulder dystocia involves the administration of various manoeuvres which aim to relieve the dystocia by manipulating the fetal shoulders and increasing the functional size of the maternal pelvis. OBJECTIVES: To assess the effects of prophylactic manoeuvres in preventing shoulder dystocia. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 June 2006). SELECTION CRITERIA: Randomised controlled trials comparing the prophylactic implementation of manoeuvres and maternal positioning with routine or standard care. DATA COLLECTION AND ANALYSIS: Two review authors independently applied exclusion criteria, assessed trial quality and extracted data. MAIN RESULTS: Two trials were included; one comparing the McRobert's manoeuvre and suprapubic pressure with no prophylactic manoeuvres in 185 women likely to give birth to a large baby and one trial comparing the use of the McRobert's manoeuvre versus lithotomy positioning in 40 women. We decided not to pool the results of the two trials. One study reported fifteen cases of shoulder dystocia in the therapeutic (control) group compared to five in the prophylactic group (relative risk (RR) 0.44, 95% confidence interval (CI) 0.17 to 1.14) and the other study reported one episode of shoulder dystocia in both prophylactic and lithotomy groups. In the first study, there were significantly more caesarean sections in the prophylactic group and when these were included in the results, significantly fewer instances of shoulder dystocia were seen in the prophylactic group (RR 0.33, 95% CI 0.12 to 0.86). In this study, thirteen women in the control group required therapeutic manoeuvres after delivery of the fetal head compared to three in the treatment group (RR 0.31, 95% CI 0.09 to 1.02). One study reported no birth injuries or low Apgar scores recorded. In the other study, one infant in the control group had a brachial plexus injury (RR 0.44, 95% CI 0.02 to 10.61), and one infant had a five-minute Apgar score less than seven (RR 0.44, 95% CI 0.02 to 10.61). AUTHORS' CONCLUSIONS: There are no clear findings to support or refute the use of prophylactic manoeuvres to prevent shoulder dystocia, although one study showed an increased rate of caesareans in the prophylactic group. Both included studies failed to address important maternal outcomes such as maternal injury, psychological outcomes and satisfaction with birth. Due to the low incidence of shoulder dystocia, trials with larger sample sizes investigating the use of such manoeuvres are required.

Delivery, Obstetric↗

PubMed1978

Functional analysis of the shoulder girdle of cats during locomotion.

The movements of the shoulder girdle of eight adult cats during overground stepping were studied, using standard slow motion cinematographic techniques. The patterns of activity of shoulder muscles were examined, using simultaneous intramuscular electromyography. Walking, trotting and galloping steps were analyzed from digitized single motion picture frame images. Angular movements of the shoulder girdle consist of biphasic flexion and extension of the shoulder joint and a monophasic flexion-extension alternation of the scapula on the thorax during each step cycle. In addition, the center of the scapula moves craniad during the swing phase and caudad during the stance phase with respect to a fixed reference point on the animal. Similar vertical movements of the center of the scapula also occur in each step cycle. Results of EMG studies of the 17 muscles capable of acting on the shoulder girdle indicate that three overall patterns of activity are found: (1) a pattern typical of extensor muscles, active during all the extension epochs; (2) a pattern typical of flexor muscles, active during the flexion epoch; and (3) a biphasic pattern of activity, active twice in each step. There data are used, along with a re-examination of previous models of the mechanics of the shoulder girdle of carnivores to examine the function and mechanics of shoulder motion. It is concluded that the rotary and translatory movements of the shoulder girdle during stepping combine to enhance step length.

Animals↗

PubMed1997

Delayed shoulder exercises in reducing seroma frequency after modified radical mastectomy: a prospective randomized study.

BACKGROUND: Seromas and impaired shoulder function are well-known complications after modified radical mastectomy for breast cancer. Early postoperative physiotherapy is a common treatment to avoid shoulder dysfunction. The aim of this study was to evaluate if the frequency of postoperative seromas could be reduced, without increasing shoulder dysfunction, by delayed postoperative shoulder exercises. METHODS: In a prospective study 163 patients with breast cancer undergoing modified radical mastectomy were randomized to physiotherapy starting on postoperative day 1 or day 7. Patients were seen by the surgeons and the physiotherapists during hospital stay and in the outpatient department. Seromas and other complications were registered by the surgeons. The physiotherapists instructed the patients pre- and postoperatively and assessed shoulder function. RESULTS: There was a significantly higher incidence of postoperative seromas in the group of patients that started physiotherapy postoperative day 1 (38%) compared to the group that started physiotherapy postoperative day 7 (22%) (p < 0.05). There was no significant difference between the groups in the late outcome of shoulder function. CONCLUSION: The incidence of seromas after modified radical mastectomy for breast cancer is reduced by delaying shoulder exercises one week postoperatively. Earlier postoperative physiotherapy is not necessary to avoid impaired shoulder function.

Aged↗

PubMed2004

Extracorporeal shockwave treatment is effective in calcific tendonitis of the shoulder. A randomized controlled trial.

BACKGROUND: Calcific tendonitis of the shoulder is often associated with chronic pain and impairment of function. Extracorporeal shockwave therapy (ESWT) is considered to be a treatment option. We compared the effects of two different ESWT regimens. METHODS: 43 patients (57 shoulders) with symptomatic calcific tendonitis of the shoulder for more than six months were included in a double-blinded study. Thirty-one shoulders were treated at the area of maximum pain with application of 2 x 2000 impulses of 0.28 mJ/mm2 at an interval of two weeks (treatment group) and 26 shoulders with 2 x 2000 impulses of < 0.07 mJ/mm2 at an interval of two weeks (control group), without pretreatment analgesia. Shoulder function (Constant score) and pain (visual analogue scale, VAS) were assessed before treatment and at one week, three months and seven months after treatment. Shoulder X-rays were performed at the 3- and 7-month follow-up visits. RESULTS: Improvement in Constant score was significantly higher in the treatment group at all follow-up visits (p < 0.05). Seven months post-treatment, calcifications dissolved completely in 19% of the treatment group and 8% of the control group, and a > 50% reduction was observed in 19% and 8% respectively. With regard to reduction of pain, there was significant improvement in the treatment group compared with the control group at the 1-week follow-up (p < 0.05). However, at the 3-month and 7-month visits, no significant between-group difference in pain could be detected. CONCLUSION: As applied, ESWT with an energy flux density of 0.28 mJ/mm2 led to a significantly greater improvement in shoulder function and a slightly higher, nonsignificant, rate of > 50% disintegration of calcific deposits compared with the control group. However, this did not result in reduction of pain.

Activities of Daily Living↗

PubMed2006

Electromyographic analysis in patients with multidirectional shoulder instability during pull, forward punch, elevation and overhead throw.

Multidirectional shoulder joint instability alters the role of dynamic stabilizers, as a result of which the motion patterns of the muscle around the shoulder joint are also changed. The aim of this study was to compare the muscle activity of patients with multidirectional shoulder instability and the control group during pull, forward punch, elevation and overhead throw. Fifteen subjects with multidirectional shoulder instability and fifteen control subjects with normal, healthy shoulders participated in the study. Both shoulders were tested in all subjects. Signals were recorded by surface EMG from eight different muscles during pull, forward punch, elevation and overhead throw. The mean and standard deviation of MVE% for the different movement types and time broadness values during overhead throw were determined for each muscle in both groups and compared with each other. Test results suggest that in case of patients with multidirectional shoulder instability the various motions are performed in a different way. The results give rise to the assumption that the centralization of the glenohumeral joint and the reduction of instability are attempted to be ensured by the organism through increasing the role of rotator cuff muscles and decreasing the role of the deltoid, biceps brachii and pectoralis maior muscles. The analysis of time broadness shows that in patients with multidirectional shoulder instability, the time difference between the peaks of normalized voluntary electrical activity is significantly greater than in the control group.

Adult↗

PubMed1998

Independent coactivation of shoulder and elbow muscles.

The aim of this study was to examine the possibility of independent muscle coactivation at the shoulder and elbow. Subjects performed rapid point-to-point movements in a horizontal plane from different initial limb configurations to a single target. EMG activity was measured from flexor and extensor muscles acting at the shoulder (pectoralis clavicular head and posterior deltoid) and elbow (biceps long head and triceps lateral head) and flexor and extensor muscles acting at both joints (biceps short head and triceps long head). Muscle coactivation was assessed by measuring tonic levels of electromyographic (EMG) activity after limb position stabilized following the end of the movements. It was observed that tonic EMG levels following movements to the same target varied as a function of the amplitude of shoulder and elbow motion. Moreover, for the movements tested here, the coactivation of shoulder and elbow muscles was found to be independent - tonic EMG activity of shoulder muscles increased in proportion to shoulder movement, but was unrelated to elbow motion, whereas elbow and double-joint muscle coactivation varied with the amplitude of elbow movement and were not correlated with shoulder motion. In addition, tonic EMG levels were higher for movements in which the shoulder and elbow rotated in the same direction than for those in which the joints rotated in opposite directions. In this respect, muscle coactivation may reflect a simple strategy to compensate for forces introduced by multijoint limb dynamics.

Elbow↗

PubMed2004

Modular total shoulder system with short stem. A prospective clinical and radiological analysis.

Between 1994 and 2001, a short-stemmed modular shoulder prosthesis was inserted in 62 shoulders in patients with rheumatoid arthritis (RA) or osteoarthrosis (OA). We reviewed 53 patients with 60 shoulders (45 RA/15 OA) with at least 24 months follow-up. In 22 shoulders, we used a total shoulder prosthesis including a glenoid polyethylene component, whereas 38 shoulders only had a humeral component. In six shoulders, the humeral component was cemented. The average follow-up was 47 (24-99) months. There were no intraoperative complications but one wound infection and one patient with proximal migration of the humeral component. Hospital for Special Surgery Score increased from 44(19-72) to 63 (21-93) points and Shoulder Function Assessment score (SFA) from 24 (12-46) to 42 (11-66)points. The VAS score for pain at rest improved from 4.3 to 1.9. Nonprogressive radiolucent lines were seen adjacent to nine glenoid and one humeral components. Fifty-six patients were satisfied with the result.

Aged↗

PubMed2006

Comparison of idiopathic, post-trauma and post-surgery frozen shoulder after manipulation under anesthesia.

Manipulation under anesthesia (MUA) has been used to speed up the recovery of frozen shoulder, which is said to be a self-limiting process. We would like to elucidate the short- and long-term results of the treatment of frozen shoulders by manipulation under anesthesia and compare the results of idiopathic, post-trauma and post-surgery frozen shoulders. We applied an adjusted Constant score (Constant score after excluding the 25 points allocated for the assessment of muscle strength) to assess all patients. In our series, 47 cases with 51 frozen shoulders were collected and evaluated retrospectively. The adjusted Constant score at pre-manipulation was on average 22.8+/-4.9 (10-31) points. The score from the 3-week follow-up was 52.6+/-9.2 (31-67) points on average. The score from the averaged 82-month follow-up was on average 70.1+/-6.2 (54-75) points, with 23 shoulders scored for a maximum point number of 75. The score at the early and late follow-ups was significantly lower for the post-surgery group (63.2+/-6.7) when compared to the other two groups (P<0.001). Our results revealed that manipulation under anaesthesia is a very simple and noninvasive procedure for shortening the course of an apparently self-limiting disease and can improve shoulder function and symptoms within a short period of time. However, we found less improvement in post-surgery frozen shoulders, especially in residual pain and limited range of motion (ROM), which may be influenced by the initial injury or initial surgery. Although less improvement in pain and ROM was noted, manipulation is still a good and simple way to treat post-surgery frozen shoulders.

Adult↗

PubMed2001

Non-operative treatment of multidirectional shoulder instability.

At an average follow-up of 3.7 years we assessed the results of non-operative treatment of 84 symptomatic shoulders in 59 patients with a diagnosis of multidirectional shoulder instability. Sixty-two shoulders had received no previous surgical treatment (group A) while 22 had failed to respond to surgical treatment before the rehabilitation programme (group B). Subjectively 11 of the non-operated shoulders (group A) were cured and 27 improved, 23 of the shoulders remained the same and one was worse at follow-up. According to the age and gender adjusted Constant score, 38 of the non-operated shoulders had either no disability or only mild disability, nine had moderate disability, while the remaining 15 had severe or total disability. These figures were far worse in group B. In group A only four shoulders required operation, while in group B seven required operation following rehabilitation. Patients who had had previous shoulder surgery, those with a work related injury and those with psychological problems were less likely to benefit from the rehabilitation programme.

Adolescent↗

PubMed2001

Radiographic assessment of scapular rotational tilt in chronic shoulder impingement syndrome.

This study presents an objective evaluation of both scapular upward and axial rotational tilts in shoulder impingement syndrome, using a scapular spine line defined on antero-posterior (AP) radiographs of the shoulder as the referential line. Twenty-seven patients with unilateral shoulder motion pain, who were diagnosed as having chronic shoulder impingement syndrome, were enrolled in the study. Scapular upward and axial rotational tilts were compared between the affected and contralateral shoulders. AP radiographs were obtained at shoulder abduction angles of 0 degrees, 45 degrees, and 90 degrees, and the X-ray films were digitized by computer. The upward and axial rotational tilts of the scapula were then evaluated on the digital images. In shoulder impingement syndrome, both upward and axial external rotations of the scapula were impaired at the painful arc angle of abduction. This tended to be more apparent for the axial rotation of the scapula than for the upward rotation. These reductions in scapular rotations reduce available clearance for the rotator cuff and humeral greater tuberosity as the shoulder is abducted.

Adult↗

PubMed1989

Fractionation sensitivity of a functional endpoint: impaired shoulder movement after post-mastectomy radiotherapy.

A clinical radiobiological study of the fractionation sensitivity of impaired shoulder movement after postmastectomy radiotherapy is presented. From 1978 to 1980, 163 breast cancer patients received postmastectomy irradiation delivered in 12 fractions, 2 fractions per week, over a period of 37 to 46 days. The total dose was specified either as a maximum absorbed dose of 51.36 Gy, or as a minimum target dose of 36.6 Gy specified at the level of midaxilla. From 1981 to 1982, 66 patients received a minimum target dose of 40.92 Gy in 22 fractions with 5 fractions per week over a period of 29 to 35 days. The treatment technique remained essentially unchanged during the whole period of 1978 to 1982. Maximal flexion and abduction of the arm were measured with unfixed scapula. A relative score, indicating the grade of impaired shoulder movement on a nominal scale from 0-3, was established by comparison with the mobility of the contralateral arm. In addition, working ability and pain at movement and at rest were evaluated. These performance parameters significantly correlated with the grade of impaired shoulder movement. The occurrence of moderately or severely impaired shoulder movement was analyzed using a mixture model incorporating dose-fractionation, latency, and predisposing clinical factors. The risk of shoulder problems was significantly higher among patients above 60 years of age. The analysis pointed to subcutaneous fibrosis as a disposing factor and indicates that postoperative physical exercise programs are beneficial. Arm edema had no statistically significant influence on shoulder performance. The alpha/beta ratio was estimated at 3.5 Gy with 95% confidence limits (c.l.) [0.7, 6.2] Gy. The length of time to expression of 90% of the ultimate frequency of moderate and severe shoulder impairment was estimated at 3.9 years with 95% confidence limits [3.1, 4.6] years. The nominal standard dose (NSD) formalism failed to produce isoeffective total doses with respect to impaired shoulder movement in the two fractionation schedules. Although the deleterious effects of larger-than-conventional dose fractions have been documented in a number of clinical series, this study represents the first quantitation of the fractionation sensitivity of a functional clinical endpoint.

Adult↗