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PubMed2004

Isometric shoulder muscle activation patterns for 3-D planar forces: a methodology for musculo-skeletal model validation.

OBJECTIVE: To present an isometric method for validation of a shoulder model simulation by means of experimentally obtained electromyography and addressing all muscles active around the shoulder joints. BACKGROUND: Analysis of muscle force distribution in the shoulder by means of electromyography during motion tasks is hampered by artificial and non-linear amplitude modulation and is often limited to downward directed external forces. This application of EMG is therefore inadequate and insufficient for the validation of shoulder model simulations. We suggest an isometric method including multi-directional forces to overcome these problems. METHODS: A force with constant magnitude is actively rotated stepwise in 20 directions perpendicular around the arm while kept in one position. The isometric muscle activation (EMG) is a function of the clockwise-rotated force angle, characterized by baseline activation, and a section of increased muscle activation characterized by baseline interception and direction and magnitude of maximum muscle activation. Comparison of the parameterized muscle activation with predicted muscle forces from model simulation illustrates the applicability for musculo-skeletal model validation. RESULTS: All recorded shoulder muscles were active over a section of force angles of at least 180 degrees. Some muscles demonstrated two activation sections. The estimated model sensitivity for the baseline interception was SD=5 degrees -10 degrees. The Principal Action was the most reliable parameter (SD=4 degrees ). A correlation of 0.778 was observed between model simulations and EMG recordings. CONCLUSIONS: The methodology addresses all shoulder muscles over a substantial section of planar force directions. This enables the comparison of experimentally determined direction of activation on- and offset and direction of maximum activation with equivalent muscle forces, predicted from model simulation.

Algorithms↗
PubMed2006

Muscles within muscles: Coordination of 19 muscle segments within three shoulder muscles during isometric motor tasks.

The aim of the present study was to determine how the intra-muscular segments of three shoulder muscles were coordinated to produce isometric force impulses around the shoulder joint and how muscle segment coordination was influenced by changes in movement direction, mechanical line of action and moment arm (ma). Twenty male subjects (mean age 22 years; range 18-30 years) with no known history of shoulder pathologies, volunteered to participate in this experiment. Utilising an electromyographic technique, the timing and intensity of contraction within 19 muscle segments of three superficial shoulder muscles (Pectoralis Major, Deltoid and Latissimus Dorsi) were studied and compared during the production of rapid (e.g. approximately 400ms time to peak) isometric force impulses in four different movement directions of the shoulder joint (flexion, extension, abduction and adduction). The results of this investigation have suggested that the timing and intensity of each muscle segment's activation was coordinated across muscles and influenced by the muscle segment's moment arm and its mechanical line of action in relation to the intended direction of shoulder movement (e.g. flexion, extension, abduction or adduction). There was also evidence that motor unit task groups were formed for individual motor tasks which comprise motor units from both adjacent and distant muscles. It was also confirmed that for any particular motor task, individual muscle segments can be functionally classified as prime mover, synergist or antagonist - classifications which are flexible from one movement to the next.

Adaptation, Physiological↗
PubMedDate not supplied

Volumetric change in the shoulder capsule after open inferior capsular shift versus arthroscopic thermal capsular shrinkage: a cadaveric model.

The purpose of this study was to compare the percentage of glenohumeral intracapsular volume reduction after open inferior capsular shift and arthroscopic thermal capsulorrhaphy. Twelve matched, fresh-frozen cadaveric shoulders were used for the study. Intraarticular glenohumeral volume measurements were obtained by injecting a viscous fatty acid sulfate solution into the joint. In the 6 right shoulders, a standard anterior-inferior capsular shift was performed, and in the 6 matching left shoulders, an arthroscopic thermal capsular shrinkage was performed. After the procedures, the capsular volumes were re-measured. The open inferior shift procedure resulted in a mean decrease in glenohumeral volume of 50.2% (range, 43%-56%). Arthroscopic thermal capsulorrhaphy decreased shoulder intraarticular volume by a mean of 29.7% (range, 26%-36%). Both the open capsular shift and arthroscopic thermal shrinkage procedures produced well-documented volumetric reductions in the shoulder capsules. The open shift reduced intraarticular shoulder volume significantly more than arthroscopic thermal capsular shrinkage.

Adult↗
PubMedDate not supplied

The anteromedial approach for shoulder arthroplasty: the importance of the anterior deltoid.

Protection of the anterior aspect of the deltoid muscle is critical to the success of shoulder arthroplasty. Between 1975 and 1980, 75 patients with 81 shoulder arthroplasties had exposure via the anteromedial approach with careful anterior deltoid detachment through fascial tissues, systematic repair, and standardized rehabilitation with early passive range of motion. As with other reports on arthroplasty, pain was significantly reduced and motion was improved. No anterior deltoid detachments occurred; deltoid strength was preserved. Greater postoperative deltoid strength was statistically associated with lesser postoperative pain, greater postoperative active elevation, improved limb function, and an enhanced overall result rating. To understand the contemporary indications for this approach better, those undergoing shoulder arthroplasty between 1990 and 1994 were assessed. The anteromedial approach was used in 14 of these 236 shoulders (5.9%). This approach is currently reserved for patients with frail anterior deltoids that will not tolerate retraction, with severely osteopenic humeral shafts that will not tolerate torsion, with extreme scarring and an inflexible deltoid muscle, with severe bony deformity, or with posterosuperior rotator cuff tearing requiring repair. The importance of the anterior deltoid in shoulder arthroplasty cannot be denied. Use of the extended deltopectoral approach with preservation of the deltoid origin insertion is a very positive step forward. In uncommon instances where added exposure is needed, the anteromedial approach with careful attention to incision and repair of the deltoid with appropriate postoperative rehabilitation can accomplish the goal of maintaining anterior deltoid function and enhancing the success of shoulder arthroplasty.

Arthroplasty, Replacement↗
PubMedDate not supplied

One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study I--clinical results.

In this prospective study on the Bristow-Latarjet repair, which started in 1980 and ended in 2001, we report the outcome in 118 shoulders where the patients have been followed up for 15 years (mean, 15.2 years; range, 14.3-20.8 years). The study was based on a physical examination, scoring with the system of Rowe et al, and the patients' subjective assessment of the operative result. After 2 years, 1 of 118 shoulders had redislocated and 98% of patients were satisfied with the operative repair. At 15 years' follow-up, 1 patient had undergone revision surgery as a result of recurrence of instability. One patient had had one redislocation during the follow-up period, and one patient reported three recurrences 3 years postoperatively. This patient has had no redislocations during the last 12 years. Furthermore, one more patient had had two recurrences 9 and 12 years after surgery but was very satisfied at follow-up. Subluxations occurred once in 4 patients and several times in 7 patients. These patients were, however, satisfied with the procedures at follow-up. One patient reported posterior subluxations at follow-up. Apprehension was significantly more common in patients with bilateral instability (P =.04) and was found in 19 of 109 shoulders. Of the patients, 90 (76%) were very satisfied with the operative result, 26 were satisfied (22%), and 1 did not know. The patient with revision surgery was considered to be dissatisfied. The incidence of bilateral shoulder instability increased from 22 of 118 (19%) at the time of surgery to 41 of 117 (35%) at 15 years after surgery. We conclude that the overall clinical results, with a satisfaction rate of 98% 15 years after the Bristow-Latarjet repair, were as good as the results reported after any operative method for recurrent anterior shoulder dislocation. However, until the radiologic part of this study is completed, we recommend the procedure only for shoulders with revision because of failed previous surgery and to surgeons familiar with the method.

Adult↗
PubMedDate not supplied

Shoulder arthrodesis: indications, technique, results, and complications.

Complications after shoulder arthrodesis are frequent. Through results and comparisons with the literature, the presented article analyzes the correlation of complications with the specific operative techniques, indications, and postoperative treatment. Between 1964 and 2001, a total of 43 cases of shoulder arthrodesis (13 screw and 30 plate arthrodeses) were performed and then analyzed after a mean of 6.7 years (range, 0.5-36 years). Surgery was carried out on 10 female patients (23%) and 33 male patients (77%) with a mean age of 35 years (range, 11-82 years). These patients had the following indications: paralysis (32 [74%]), osteoarthritis or humeral head necrosis (15 [35%]), infection (7 [16%]), and persistent shoulder instability (6 [14%]). The extent of active movement after arthrodesis was 56 degrees abduction (range, 20 degrees - 90 degrees) and 60 degrees forward flexion (range, 20 degrees - 105 degrees), with an increase in the Constant score in all cases, from a mean of 27 points preoperatively to 57 points postoperatively (difference, 30 points). The patients rated the outcome of surgery as excellent, good, or satisfactory in 91% of cases. Complications after shoulder arthrodesis were noted in 12 of 43 patients (28%). The most frequent complications after screw/plate arthrodesis included pseudarthrosis, 2 (15%)/3 (10%); infection, 1 (8%)/4 (13%); and fracture of the humerus, 0/4 (13%). No specific judgment can be attributed to the different osteosynthesis techniques used in shoulder arthrodesis, either in the cases presented at our clinic or in the literature. Pseudarthrosis appeared to be less frequent in cases of plate arthrodesis compared with screw arthrodesis. However, the application of plates resulted more often in infection, postoperative fractures of the humerus, and the necessity for removal of material. Particularly in patients with paralysis, a shoulder arthrodesis resulted in an improvement in postoperative active function and presented a suitable operative option.

Adolescent↗
PubMedDate not supplied

Development of a Flexilevel Scale for use with computer-adaptive testing for assessing shoulder function.

In a 5-year study, a self-report measure of shoulder function-the Flexilevel Scale of Shoulder Function (FLEX-SF)-was developed by use of item response theory. A large pool of candidate items (N = 68) was developed. A questionnaire that included the 68 items, another scale of shoulder function, and clinical and demographic questions were administered to 400 persons with shoulder complaints. Patients' responses to the 68 items were calibrated by use of Andrich's rating scale model. Thirty-three items were selected from the pool and subdivided into three overlapping testlets targeting low, medium, and high shoulder function. A table translates raw scores on testlets to a common mathematical metric. The validity and reliability of the FLEX-SF was evaluated in a longitudinal study of 199 patients. The FLEX-SF scores were highly reliable and exhibited excellent validity (including responsiveness). We report on a simulation of a computer-adaptive test of shoulder function. This simulation is based on the developmental items we tested for use in the FLEX-SF. The results indicate that greater measurement efficiency can be achieved with a computer-adaptive test format.

Computer Simulation↗
PubMedDate not supplied

Total shoulder arthroplasty: long-term survivorship, functional outcome, and quality of life.

This study examines long-term outcomes of total shoulder arthroplasty (TSA) via survivorship analysis, patient questionnaires, and minimum 10-year physical examinations. The study group consisted of 320 consecutive TSAs performed in 267 patients between 1974 and 1988. Diagnoses included rheumatoid arthritis (69%), osteoarthritis (22%), and juvenile rheumatoid arthritis (4.7%). Minimum 10-year physical examination follow-up was obtained on a subset of 72 TSAs at a mean (+/- SD) of 14.0 +/- 2.7 years. A Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was obtained from 80 patients with 103 TSAs at a mean of 15.4 +/- 3.4 years after the index procedure (range, 10.4-23.2 years). Kaplan-Meier survivorship rates with revision as the endpoint at 5, 10, 15, and 20 years were 98%, 93%, 88%, and 85%, respectively. Of the shoulders, 22 (6.9%) required a revision, most commonly for loosening of one or both components (15 shoulders). Dislocation occurred earlier than other causes of revision or complication (P < .05, analysis of variance). Minimum 10-year physical examination follow-up revealed lasting, significant improvements in range of motion and strength. The patients' subjective assessments of TSA were favorable in that 92% felt that their shoulder was "much better" or "better" after TSA. The mean DASH score was 49 +/- 25; no significant differences were found among diagnoses. Long-term analysis of the Neer-type TSA revealed survivorship rates comparable to other joint replacements. The significant improvements in relief of pain, shoulder range of motion, and strength are associated with a high degree of patient satisfaction.

Adolescent↗
PubMed2006

Expression of vascular endothelial growth factor and angiogenesis in the diabetic frozen shoulder.

The purpose of this study was to investigate neovascularization and the expression of vascular endothelial growth factor (VEGF) in patients with diabetic frozen shoulders. Eleven patients with diabetic frozen shoulders underwent arthroscopic lysis of adhesions, and we observed the reported findings. VEGF expression was determined by immunohistochemistry and Western blot analysis, and the density of vessels was evaluated based on CD34 immunoreactivity by use of samples of the synovial tissue. For the control group, we took 5 samples of synovium from patients undergoing shoulder arthroscopy. The arthroscopic findings showed hyperemia of the synovial tissue in all cases of diabetic frozen shoulder. This synovium showed stronger immunostaining to VEGF (P = .010) and CD34 (P = .011) than the control synovial tissue. Western blot analysis also showed a stronger VEGF intensity than in the control group. We postulate that VEGF is synthesized and secreted in the synovium of diabetic frozen shoulders and VEGF may have some role in the pathogenesis and neovascularization of frozen shoulders in diabetic patients.

Aged↗
PubMed2004

Clinical evaluation of the shoulder.

Shoulder pain is an exceptionally common problem in physiatric practice. Evaluation and management of patients with shoulder dysfunction can challenge even the most experienced practitioner. The complexity and inherent instability of the shoulder lead to functional overload of various bony and soft tissues within the joint complex and adjacent structures.Additionally, shoulder pain may be the initial manifestation of a potentially serious condition. Consequently, a detailed and systematic approach to the evaluation of a patient with shoulder pain is crucial in establishing a complete and accurate diagnosis. A skillfully performed history and physical examination allows identification of specific tissue pain generators and biomechanical dysfunction throughout the kinetic chain. Only after these elements have been defined clearly can an appropriate rehabilitation program be de-signed. A thorough clinical assessment also can aid in the detection of serious diseases that masquerade as shoulder pain. An effective clinical evaluation enhances the quality and cost-effectiveness of care and facilitates a successful outcome in most cases.

Diagnosis, Differential↗
PubMed2005

[Scapulohumeral arthrodesis for non-neurological shoulder: a study of 8 cases].

PURPOSE OF THE STUDY: Scapulohumeral arthrodesis is mainly used for the treatment of sequelar injury after brachial plexus palsy. Indications are however controversial and limited to patients with non-neurological shoulders. We report a series of eight shoulder arthrodeses performed on non-neurological shoulders in order to determine and detail the current role of this procedure. PATIENTS AND METHODS: The series included eight patients, five men and three women, mean age 47 years (23-87). The dominant side was operated on in two patients and the non-dominant side in six. Seven patients had had at least one shoulder procedure prior to arthrodesis. Arthrodesis was performed for foreign body reaction on a tendon prosthesis in one patients, posttraumatic head necrosis in two, off-centered degenerative joint disease with full thickness rotator cuff tear in three, and multi-directional instability on degenerative joint disease in two. Arthrodesis was performed via a posterior approach in all patients but one using screw fixation associated with external fixation left in place for 2.5 months on average. RESULTS: All patients except one were satisfied with the outcome (basically because of pain relief). Mean active motion was 75 degrees flexion, 65 degrees abduction (arthrodesis at 20 degrees flexion, 25 degrees abduction and 30 degrees internal rotation). Two groups were identified to analyse the absolute Constant score. The score improved 16 points (from 24 to 40) in the group of patients without instability (pain score improved from 3 to 13) and decreased 14 points (from 66 to 52) in the group with instability (due to decreased motion, the mean motion score declining from 38 to 14). Complications included one radial palsy, one nonunion, and one gravity edema of the upper limb. DISCUSSION AND CONCLUSION: Shoulder arthrodesis is more than a salvage method to reduce pain and gain stability. The objective should be to recover useful function (hand-mouth, hand-perineum, brachio-thoracic function). It should be used when prosthetic arthroplasty is not possible (infectious arthritis, advanced degenerative disease in young subjects, loss of glenoid bone stock, failure after treatment of multidirectional instability with degenerative disease). Shoulder arthrodesis still has rare indications because of the predictability of sustained outcome.

Adult↗
PubMed2003

Latissimus dorsi transfer for external rotation weakness of the shoulder in obstetric brachial plexus palsy.

This report describes the results of latissimus dorsi transfer for weakness of shoulder external rotation in 12 children with obstetric brachial plexus palsy. Selection criteria for the muscle transfer procedure included good passive external rotation of the shoulder, normal skeletal development of the shoulder joint, and adequate power of the deltoid. In addition to measuring the ranges of motion of joints before and after surgery, a modified Mallet grading system was utilized for the functional assessment of shoulder external rotation. At a mean follow-up of 4 years, two of the 12 children had recurrence of the shoulder deformity. In the remaining 10 children, the mean active external rotation was 30 degrees (range, 20-60 degrees ), mean shoulder abduction was 140 degrees (range, 90-170 degrees ), and all children had achieved a modified Mallet score of 4.

Brachial Plexus↗
PubMed2000

EMG and strength correlates of selected shoulder muscles during rotations of the glenohumeral joint.

OBJECTIVE: To identify activation patterns of several muscles acting on the shoulder joint during isokinetic internal and external rotation. DESIGN: Combined EMG and isokinetic strength analysis in healthy subjects. BACKGROUND: EMG studies of the shoulder region revealed intricate muscular activation patterns during elevation of the arm but no parallel studies regarding pure rotations of the joint could be located. METHODS: Fifteen (n=30 shoulders) young, asymptomatic male subjects participated in the study. Strength production during isokinetic concentric and eccentric internal and external rotations at 60 and 180 degrees /s was correlated with the EMG activity of the rotator cuff, biceps, deltoid and pectoralis major. Analysis of the smoothed EMG related to the timing of onset of the signal and to the normalized activity at the angle of the peak moment. Determination of the association between the EMG and the moment was based on strength ratios. RESULTS: Findings indicated that for both types of rotations, the rotator cuff and biceps were active 0.092+/-0.038-0.215+/-0.045 s prior to the initiation of the actual movement and 0.112-0.034 s prior to onset of deltoid and pectoralis major activity. These differences were significant in all of the eight conditions (P<0.05). In terms of the strength ratios, strong association was found between electrical activity and moment production in the subscapularis and infraspinatus (r(2)=0.95 and 0. 72, respectively) at the low and high angular velocities. CONCLUSIONS: Prior to actual rotation of the shoulder joint, normal recruitment of the rotator cuff and biceps is characterized by a non-specific presetting phase which is mainly directed at enhancing the joint 'stiffness' and hence its stability. Once movement is in progress, the EMG patterns of these muscles become movement specific and are correlated with the resultant moment. RELEVANCE: Muscular dysfunction relating to delayed onset activity or altered activation patterns, due to pain, perturbed mechanics or disturbed neural activation have been implicated as concomitant factors in other joint associated pathologies. Through highlighting the role of the rotator cuff in shoulder joint rotations, this study lends further support to the argument that a parallel situation may prevail with respect to shoulder joint dysfunction. This could lead to the development of rehabilitation protocols aimed specifically at redressing such dysfunction.

Adolescent↗
PubMed2003

Coactivation in arm and shoulder muscles during voluntary fixation of a single joint.

The objective of this study was to determine the organization of coactivation in the arm and shoulder muscles. Normal human subjects made alternate movements of a joint in the horizontal plane, either adduction-abduction of the second finger and shoulder, ulnar-radial deviation of the wrist, or extension-flexion of the elbow, during which they fixed a focal joint while decreasing the movement amplitude and increasing the fixation strength. They varied the fixation strength at four different levels up to the maximum. The focal-joint angle, and surface electromyograms (EMGs) from the intrinsic hand, antebrachial, upper-arm, and shoulder muscles were recorded. EMGs in the phase of fixation were quantified by integration after rectification. The degree of coactivation among the muscles was evaluated by calculating correlation coefficients across the integrated EMGs. There were correlations in the integrated EMGs among focal-joint muscles (FJMs), and also between one of the FJMs and the muscles distal and/or proximal to the FJMs: in the finger fixation between the hand and antebrachial muscles, in the wrist fixation between the antebrachial and hand/upper-arm muscles, in the elbow fixation between the upper-arm and antebrachial/shoulder muscles, and in the shoulder fixation between the shoulder and upper-arm muscles. Moderate or slight correlations were seen in muscles more distant from FJMs. Our results indicate that the longitudinal distance from FJMs in the shoulder and arm muscles is an important factor in determining levels of coactivation. This is discussed in relation to the fact that neighboring muscles share joints with FJMs.

Adolescent↗
PubMed1985

Anterior portal selection for shoulder arthroscopy.

A posterior portal site has become the accepted standard for introduction of the arthroscope for routine diagnostic procedures of the shoulder. Few published guidelines exist, however, on the optimum and safe positions of accessory portals for introduction of a probe or surgical instruments during shoulder arthroscopy. The relatively thick surrounding muscle layers and the close proximity of vital neurovascular structures would make guidelines for safer and more reproducible accessory portal selection helpful to minimize the risk of injury to these structures. The "intraarticular triangle" bounded by the humeral head, the glenoid rim, and the biceps tendon has been found to be an excellent intraarticular landmark for placement of an accessory anterior portal for shoulder arthroscopy. Anatomical dissections on 20 cadaver shoulders have confirmed that instruments passed through this location are at little risk to injure adjacent neurovascular structures about the shoulder. Clinical data in 30 shoulder arthroscopies performed utilizing this landmark for placement of an anterior portal have confirmed this position to be a safe and useful location for portal placement if proper precautions are followed.

Arthroscopy↗
PubMedDate not supplied

Intratester and intertester reliability of goniometric measurement of passive lateral shoulder rotation.

Measurement of lateral rotation range of motion (ROM) is frequently performed during shoulder evaluation. The purpose of this study was to determine the intratester and intertester reliability of goniometric measurement of passive lateral rotation ROM of the shoulder. Two experienced PTs performed the testing in a randomized block design. They were blinded to all clinical information and to their goniometric readings. Passive lateral rotation ROM of the shoulder was assessed in 34 patients with a variety of shoulder pathologies. Patients were placed in the supine position with the arm abducted approximately 20 degrees to 30 degrees. A standard goniometer, placed along the joint axis by the therapist, was red by an independent assistant. Intraclass correlation coefficients (ICCs) and their associated 95% confidence intervals were calculated. Intratherapist ICCs (0.88 and 0.93) and intertherapist ICCs (0.85 and 0.80) were high. These findings suggest that reliable measures of passive lateral rotation ROM of the shoulder can be obtained from patients with shoulder pathology using standard goniometry and by placing the patient in a supine position.

Humans↗
PubMed2001

Topography of muscle spindles and Golgi tendon organs in shoulder muscles of "Monodelphis domestica".

The topography of muscle spindles and Golgi tendon organs in the rotator cuff and surrounding shoulder muscles of a small laboratory marsupial (monodelphis domestica) were studied using light microscopy of serial sections. The shoulder joint of monodelphis has a large degree of freedom of movement allowing this animal to use the upper extremities for a wide range of activities like climbing and manipulating food. Thus, similar to the situation in man the shoulder joint is mainly secured by muscles. Silver stained serial paraffin sections were examined under the light microscope and the distribution of muscle spindles and Golgi tendon organs was reconstructed using three-dimensional image processing. In the two animals examined 113 and 131 muscle spindles respectively were found within the 4 rotator cuff muscles. In addition, 76 and 40 Golgi tendon organs respectively were seen at the musculo-tendinous junctions of these muscles preferentially close to the insertion at the humerus head. Also the surrounding shoulder muscles contain both muscle spindles and Golgi tendon organs in large numbers, but the ratio of Golgi tendon organs per muscle spindle appears to be lower. Number and localization of muscle spindles and Golgi tendon organs suggest, that these receptors are important for both reflex control of shoulder muscle tone as well as monitoring of static position and movement in the shoulder joint.

Animals↗
PubMed2003

Shoulder pain and disability in daily life, following supraomohyoid neck dissection: a pilot study.

INTRODUCTION: The purpose of this pilot study was to assess shoulder morbidity; i.e. pain and disability in daily activities, at least 1 year after unilateral or bilateral supraomohyoid neck dissection. PATIENTS AND METHODS: 52 patients having been subjected to a supraomohyoid neck dissection completed a questionnaire assessing pain and daily activities. RESULTS: 14 (28%) patients complained of ipsilateral shoulder pain following supraomohyoid neck dissection. The disability from shoulder complaints as perceived during daily life was minor. The pain and disability experienced during daily activities led to dependency upon other people in two patients. This dependency only existed during heavy household activities. CONCLUSION: Despite the fact that this type of neck dissection was developed to reduce shoulder morbidity, 28% of the patients experienced shoulder pain following supraomohyoid neck dissection. The degree of disability due to shoulder complaints, however, was minor.

Activities of Daily Living↗