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PubMed2006

The modified axillary view of the shoulder, a painless alternative.

BACKGROUND: In our department, axillary views of the shoulder in trauma patients are not performed on a routine base, but sometimes, they are ordered by the trauma surgeon. We usually perform an anteroposterior view of the shoulder, combined with a posterior and an anterior oblique view of the shoulder in trauma patients. Because the classical described axillary view of the shoulder is sometimes very painful for the patient, especially in patients with humeral fractures, we perform a less painful modified axillary view. METHODS: We now perform the axillary view with the patient standing upright and bending forward and we give a craniocaudal tube inclination between 30 and 45 degrees. Doing so, we also have an "axillary" view on the shoulder, but without harm for the patient. We performed a retrospective study in 103 patients with a modified axillary view and the additional value was checked. CONCLUSION: We conclude that the modified axillary view is useful in 30 patients for detection of Hill-Sachs lesions or evaluation for displacement or angulation in proximal humeral fractures.

Adolescent↗
PubMed2007

Changes in shoulder muscle size and activity following treatment for breast cancer.

BACKGROUND: Morbidity of the shoulder after breast cancer is a well-known phenomenon. MRI studies have shown muscle morbidity in cervical cancer and prostate cancer. In breast cancer clinical observations and patient reports include muscle morbidity in a number of muscles acting at the shoulder. Several of these muscles lie in the field of surgery and radiotherapy. Timed interaction between muscles that stabilise the shoulder and those acting as prime movers is essential to achieve a smooth scapulohumeral rthythm during functional elevation of the arm. METHOD: CROSS-SECTIONAL STUDY: Seventy-four women treated for unilateral carcinoma of the breast were included in the study. All patients filled out the Shoulder Pain and Disability Index (SPADI). EMG activity of four muscles was recorded during scaption on the affected and unaffected side. Muscle cross sectional area and signal intensity was determined from MRI scans. The association between EMG and covariates was determined using multiple linear regression techniques. RESULTS: Three of the 4 muscles on the affected side demonstrated significantly less EMG activity, particularly when lowering the arm. Upper trapezius demonstrated the greatest loss in activity. Decreased activity in both upper trapezius and rhomboid were significantly associated with an increase in SPADI score and increased time since surgery. Pectoralis major and minor were significantly smaller on the affected side. CONCLUSION: Muscles affected in the long term are the muscles associated with pain and disability yet are not in the direct field of surgery or radiotherapy. Primary muscle shortening and secondary loss of muscle activity may be producing a movement disorder similar to the 'Dropped Shoulder Syndrome'. Exercise programmes should aim not only for range of movement but also for posture correction and education of potential long-term effects.

Aged↗
PubMed1992

Towards a model for force predictions in the human shoulder.

In this paper the concept of a three-dimensional biomechanical model of the human shoulder is introduced. This model is used to analyze static load sharing between the muscles, the bones and the ligaments. The model consists of all shoulder structures, which means that different positions and different load situations may be analyzed using the same model. Solutions can be found for the complete range of shoulder motion. However, this article focuses only on elevation in the scapular plane and on forces in structures attached to the humerus. The intention is to expand the model in future studies to also involve the forces acting on the other shoulder bones: the scapula and the clavicle. The musculoskeletal forces in the shoulder complex are predicted utilizing the optimization technique with the sum of squared muscle stresses as an objective function. Numerical results predict that among the muscles crossing the glenohumeral joint parts of the deltoideus, the infraspinatus, the supraspinatus, the subscapularis, the pectoralis major, the coracobrachialis and the biceps are the muscles most activated during this sort of abduction. Muscle-force levels reached values of 150 N when the hand load was 1 kg. The results from the model seem to be qualitatively accurate, but it is concluded that in the future development of the model the direction of the contact force in the glenohumeral joint must be constrained.

Arm↗
PubMed1994

Analysis of the kinematic and dynamic behavior of the shoulder mechanism.

A finite element musculoskeletal model of the shoulder mechanism consisting of the thorax, clavicula, scapula and humerus has been used for analysis of the kinematic and dynamic behavior. The model includes 16 muscles, three joints, three extracapsular ligaments and the motion constraints of the scapulothoracic gliding plane which turns the shoulder girdle into a closed-chain mechanism. Simulations are inverse dynamic. Input variables are the positions of the shoulder girdle and humerus which have been recorded in 10 subjects during unloaded and loaded humeral abduction and anteflexion. Comparisons of muscle force predictions and EMG recordings are hampered by the unknown force-length relationship and the length dependency of EMG amplitude. It is concluded that EMG amplitude cannot be used for validation of complex musculoskeletal models. Muscle function is analyzed with help of a force and moment balance of the three joints. The moment balance includes the contributions of ligaments and the reaction forces at the scapulothoracic gliding plane. The scapulothoracic gliding plane is very important for the motions and the stabilization of the shoulder girdle. The direction and magnitude of joint reaction forces are calculated as well. It is concluded that the model provides good insight into the mechanics of the shoulder mechanism and that it enables an analysis of the function of morphological structures.

Acromioclavicular Joint↗
PubMed1995

Arthroscopic Bankart suture repair for recurrent traumatic unidirectional anterior shoulder dislocations.

We report our experience with arthroscopic repair of the Bankart lesion following traumatic unidirectional anterior shoulder dislocation. Thirty consecutive patients (7 women, 23 men; average age, 26.5 years) were followed for an average of 38 months (minimum 2-year follow-up) after arthroscopic Bankart suture repair for recurrent shoulder dislocation. The study included patients who had pure shoulder dislocations (excluding those with instability secondary to subluxation, multidirectional instability, or an atraumatic origin), had experienced an initial frank shoulder dislocation (documented radiographically or requiring the assistance of medical personnel for reduction), and had a Bankart lesion, visualized arthroscopically. Clinical evaluation using the Rowe functional grading system showed 11 patients rated as excellent, 8 as good, 3 as fair, and 8 as poor. Six of 8 patients were rated as poor because they frankly redislocated following their arthroscopic shoulder stabilization. Our study shows a 27% failure rate in this group. Critical reevaluation of the transglenoid arthroscopic Bankart procedure is mandatory to identify the appropriate patient population for this procedure.

Adult↗
PubMed1995

Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability.

The avulsion of the glenohumeral ligament labral complex at the glenoid (Bankart lesion), as well as ligamentous laxity are well known causes of anterior shoulder instability. A lesser known entity, the humeral avulsion of glenohumeral ligaments (HAGL), was studied to determine its incidence and its role in anterior glenohumeral instability. Sixty-four shoulders with the diagnosis of anterior instability were prospectively evaluated by arthroscopy for intraarticular pathology, including Bankart, capsular laxity, and HAGL lesions. Six shoulders were found to have HAGL lesions (9.3%), 11 shoulders with generalized capsular laxity (17.2%), and 47 shoulders with Bankart lesions (73.5%). In patients with documented anterior instability without a demonstratable "primary" Bankart lesion, a HAGL lesion should be ruled out. This lesion is readily recognized arthroscopically, and an appropriate repair of this lesion can restore anterior stability to the patient. The pathological anatomy of the HAGL lesion and our treatment of this lesion is discussed.

Adolescent↗
PubMed2004

Arthroscopic versus open treatment of Bankart lesion of the shoulder: a prospective randomized study.

PURPOSE: The purpose of this study was to compare the results of arthroscopic and open repair of isolated Bankart lesions of the shoulder using metallic suture anchors. TYPE OF STUDY: Prospective randomized clinical study. METHODS: Sixty patients with traumatic anterior shoulder instability underwent a surgical repair of an isolated Bankart lesion. The patients were divided into 2 groups of 30 patients each. In group 1, an arthroscopic repair was performed, and in group 2, an open procedure was performed. The groups were homogeneous for gender, age, dominance, number of dislocations, time elapsed between first dislocation and surgery, and pathologic findings. In all cases of both groups, the lesion was repaired using metallic suture anchors carrying nonabsorbable braided sutures. Postoperative rehabilitation was the same for the 2 groups. Two years' follow-up evaluation included Constant and Rowe shoulder scores. Statistical analysis of data was performed using an unpaired t test (significance for P <.05). RESULTS: No recurrence of dislocation of the involved shoulder has been reported in either group. Follow-up Constant and Rowe scores of the 2 groups were not significantly different. The only significant difference seen between the 2 groups was for range of motion evaluation with the Constant score. The mean value for group 1 (39.6 +/- 0.8) was significantly greater (P =.017) than that for group 2 (37.8 +/- 2.0). CONCLUSIONS: Arthroscopic repair with suture anchors is an effective surgical technique for the treatment of an isolated Bankart lesion. Open repair does not offer a significantly better 2-year result in terms of stability, and furthermore, can negatively affect the recovery of full range of motion of the shoulder. LEVEL OF EVIDENCE: Level I.

Adult↗
PubMed2006

Arthroscopic stabilization in anterior shoulder instability: collision athletes versus noncollision athletes.

PURPOSE: Collision athletes have been reported to be at high risk of redislocation after stabilization for anterior shoulder instability. However, few studies have compared the results of arthroscopic stabilization with collision and noncollision athletes. The purposes of this study were to analyze clinical outcomes of arthroscopic anterior shoulder stabilization in athletes and to compare the results between collision and noncollision athletes. METHODS: A total of 29 athletes were enrolled in this study, including 14 collision athletes and 15 noncollision athletes. Mean age at the time of operation was 21.1 years, and mean follow-up period was 62.1 months (range, 25 to 117 months). All shoulders underwent arthroscopic stabilization. RESULTS: Visual analogue scale score, Rowe score, and Constant score improved after surgery (P < .05), but no statistically significant difference was found between collision and noncollision groups (P < .05). In all, 19 athletes (65.5%) returned to near preinjury sports activity levels (90% or greater recovery) after operation. Five athletes (17.2%) experienced postoperative instability. One (3.4%) had subluxation and 4 (13.8%) had redislocation after surgery. Four cases in the collision group (28.6%) and 1 in the noncollision group (6.7%) had postoperative subluxation or dislocation (P = .118). CONCLUSIONS: Arthroscopic stabilization for anterior instability of the shoulder is a reliable procedure with respect to shoulder function, range of motion, and postoperative return to sports activities in athletes. However, a high recurrence rate (17.2%) was observed among athletes. Compared with the noncollision group (6.7%), the collision group yielded a higher failure rate (28.6%) than was expected. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Adolescent↗
PubMed2006

An evaluation of the shoulder domain of the University of Washington quality of life scale.

UNLABELLED: The aim of this study was to compare the shoulder domain in the University of Washington quality of life (UW-QoL) scale with two shoulder-specific questionnaires. METHODS: We did a cross-sectional survey of 100 consecutive outpatients who had had operations on the head and neck for cancer using the UW-QoL, the neck dissection impairment index, and the shoulder disability questionnaire. RESULTS: The types of neck dissection were none (n=12), unilateral selective (n=63), bilateral selective (n=17), and radical or modified radical (n=8). There were significant correlations among the three questionnaires. The worst scores were found in the group who had modified radical or radical neck dissection. Although responses were similar between those who had no neck dissection and those who had unilateral level 3 neck dissection, a few patients reported considerable dysfunction after selective neck dissection. CONCLUSION: Although the UW-QoL shoulder domain is limited to one of four responses, our results support the conclusion that it is sufficiently sensitive to screen for dysfunction of the shoulder.

Activities of Daily Living↗
PubMed2005

The rheumatoid shoulder: current consensus on diagnosis and treatment.

Shoulder involvement is usually inconspicuous in patients with rheumatoid arthritis, and the clinical manifestations are nonspecific. Nevertheless, shoulder involvement should be sought routinely and detected early. Range of motion at the shoulder should be evaluated. Although normal radiographic findings do not rule out shoulder involvement, radiographs are crucial for detecting micro- and macro-geodes during follow-up. The development of glenohumeral joint space narrowing is a turning point that indicates a risk of rapid joint destruction. Magnetic resonance imaging is useful for assessing the lesions and guiding the treatment strategy. Stepwise use of local interventions as indicated by imaging findings is recommended. Joint replacement should not be left too late, and surgical procedures on the shoulder should be built into the overall treatment plan.

Arthritis, Rheumatoid↗
PubMed2006

Clinical measurement of posterior shoulder flexibility.

The objectives of this study were to determine both the intra-rater reliability and the smallest real difference necessary to detect meaningful clinical changes over an 8-12 week period for three clinical measures of posterior shoulder flexibility. Posterior shoulder tightness has been associated with abnormal humeral head translations that narrow the subacromial space and contribute to impingement. Posterior shoulder stretching to normalize joint kinematics is often used when treating individuals with subacromial impingement. Currently there is no measurement of posterior shoulder flexibility that has been demonstrated to be reliable or responsive in patients over a treatment interval. Construction workers with overhead work exposure were recruited to an impingement group (n=37), and an asymptomatic group (n=22). Three flexibility measurements were taken on each subject at baseline and 8-12 weeks later by the same physical therapist. Intra-rater reliability was determined using intra-class correlation coefficients (ICCs) and standard errors of measurement (SEM). The smallest real difference value (SRD) determined the smallest detectable intervention-related measurement change over time. ICCs for the three measurements ranged from poor (0.40) to good (0.79). The SEM and SRD values reflected high test-retest variability in all three measurements. None of the three measures were proven to be highly stable indicators of posterior shoulder flexibility over this time period, nor were they able to detect small changes over this interval due to the high trial to trial variance in a non-intervention sample. Caution should be used when interpreting these clinical measurements over prolonged time periods.

Analysis of Variance↗
PubMed2003

Shoulder pain, range of motion, and functional motor skills after acute tetraplegia.

OBJECTIVES: To investigate (1) the prevalence and course of shoulder pain in acute tetraplegia and (2) its relationship with range of motion (ROM) and function and any associated risk factors. DESIGN: A longitudinal prospective study. SETTING: Spinal injury unit in an Australian hospital. PARTICIPANTS: Inpatients with acute tetraplegia. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographics, pain intensity, shoulder ROM, and functional motor skills. RESULTS: The prevalence of pain during rehabilitation was 85%. Risk factors associated with pain during rehabilitation included age less than 30 years or more than 50 years (F=8.892, P=.064), admission motor level at C2-5 (F=5.833, P=.016), admission sensory level at C2-5 (F=7.543, P=.006), lower left upper limb (P=.005; 95% confidence interval [CI], -14.74 to -2.86) and total American Spinal Injury Association motor scores (P=.009; 95% CI, -29.53 to -4.67), and a shorter duration of bedrest (F=5.794, P=.055). Subjects with pain lost ROM in left abduction (P=.038; 95% CI, -25.9 to -0.9) and right abduction (P=.05; 95% CI, -30 to 9.3). No relationship existed between shoulder pain and functional motor skills on discharge. CONCLUSION: Shoulder pain is common in acute tetraplegia and is associated with loss of shoulder ROM. Risk factors identified include age, injury level, and duration of bedrest. Areas for further study are identified.

Acute Disease↗
PubMed2003

A trial into the effectiveness of soft tissue massage in the treatment of shoulder pain.

The purpose of this single blinded randomised controlled trial was to investigate the effects of soft tissue massage on range of motion, reported pain and reported function in patients with shoulder pain. Twenty-nine patients referred to physiotherapy for shoulder pain were randomly assigned to a treatment group that received six treatments of soft tissue massage around the shoulder (n = 15) or to a control group that received no treatment while on the waiting list for two weeks (n = 14). Measurements were taken both before and after the experimental period by a blinded assessor. Active range of motion was measured for flexion, abduction and hand-behind-back movements. Pain was assessed with the Short Form McGill Pain Questionnaire (SFMPQ) and functional ability was assessed with the Patient Specific Functional Disability Measure (PSFDM). The treatment group showed significant improvements in range of motion compared with the control group for abduction (mean 42.2 degrees, 95% CI 24.1 to 60.4 degrees), flexion (mean 22.6 degrees, 95% CI 12.4 to 32.8 degrees) and hand-behind-back (mean 11.0 cm improvement, 95% CI 6.3 to 15.6 cm). Massage reduced pain as reported on the descriptive section of the SFMPQ by a mean of 4.9 points (95% CI 2.5 to 7.2 points) and on the visual analogue scale by an average of 26.5 mm (95% CI 5.3 to 47.6 mm), and it improved reported function on the PSFDM by a mean of 8.6 points (95% CI 4.9 to 12.3 points). We conclude that soft tissue massage around the shoulder is effective in improving range of motion, pain and function in patients with shoulder pain. The mechanisms behind these effects remain unclear.

Adult↗
PubMed1998

Primary replacement of the humeral head in iatrogenically displaced fracture-dislocations of the shoulder: a report about six cases.

Dislocation of the shoulder is a common injury and may be associated with a variety of complications. We report six cases of primary replacement of the humeral head where closed reduction of a shoulder dislocation associated with an undisplaced fracture of the humeral neck led to displacement of the neck fracture. All dislocations examined were anterior with a displaced greater tubercle fracture. The patients had undergone closed reduction at other medical centres and were referred to us because of iatrogenically displaced fracture-dislocations of the shoulder. Three were women and three were men with a mean age of 52.8 years (range 38-72). Primary replacement of the humeral head was done in an average of 9.3 days (range 2-30 days) following the injury. The average follow-up period was 30.2 months (range 12-55 months). Postoperative pain, active range of motion and function were evaluated with the American Shoulder and Elbow Surgeons Criteria. The forward flexion averaged 124 degrees, active external rotation averaged 29 degrees and internal rotation (achieved movement) to the second lumbar vertebra. Because of the high risk of avascular necrosis and severe collapse of the humeral head, we conclude that the primary replacement of the humeral head is the superior treatment option in iatrogenically displaced fracture dislocations of the shoulder.

Adult↗
PubMed1999

Measuring muscle and joint geometry parameters of a shoulder for modeling purposes.

An extensive set of muscle and joint geometry parameters was measured of the right shoulder of an embalmed male. For all muscles the optimal muscle fiber length was determined by laser diffraction measurements of sarcomere length. In addition, tendon length and physiological cross-sectional area were determined. The parameter set was needed to enhance the reliability of a computer model of the shoulder (Van der Helm, 1994a,b Journal of Biomechanics 27, 527-550, 551-569). With the model, an abduction of the arm was simulated in seven positions, at 30 degrees intervals. In each of the simulated arm positions, actual sarcomere lengths were calculated from the lengths of 104 muscle elements, distributed over 16 shoulder muscles. For most muscle elements, the simulated abduction appeared to take place within the sarcomere length range in which the muscle elements can exert force. The muscle elements can then act on the ascending limb as well as on the plateau and on the descending limb of the relative force-length curves of sarcomeres. The produced data set is not only important for the refinement of shoulder modeling, but also for functional analyses of shoulder movements in general.

Cadaver↗
PubMed2003

Ganglion cysts of the shoulder: technique of arthroscopic decompression and fixation of associated type II superior labral anterior to posterior lesions.

Ganglion cysts of the shoulder and concomitant suprascapular nerve compression should be considered in the differential diagnosis of shoulder pain. They are associated commonly with labral tears, most commonly SLAP lesions. MRI has become commonplace in evaluating shoulder pain and has led to the increased awareness of shoulder cysts. MRI accurately demonstrates the size and location of ganglions, which is critical when planning surgical intervention. It also has shown the frequent association of intra-articular pathology with these cysts. Despite that MRI can detect atrophy, the diagnosis of suprascapular nerve compression can be confirmed only by EMG/NCS, because the presence of a cyst does not necessarily mean the nerve is compressed. Likewise, a positive EMG does not confirm that the compression is caused by a ganglion cyst. EMG/NCVs are necessary for confirming the diagnosis and evaluating nerve and muscle function. A trial of nonoperative management is warranted; however, this is associated with a high failure rate. Aspiration techniques are successful for decompression of the cysts and initial pain relief; however, the intra-articular pathology is not addressed and there is a higher rate of recurrence. Open resection of the ganglion cyst is successful; however, the intra-articular labral tears are not addressed, which can lead to recurrence and the morbidity of the cyst excision is not warranted. Shoulder arthroscopy has led to the identification of associated intra-articular pathology such as SLAP lesions. These were not appreciated previously with open surgery and therefore were not addressed. Arthroscopic techniques have evolved to allow decompression of the ganglion cysts and repair of the labral lesions. This should decrease the possibility of recurrence of the cyst by eliminating the cyst and the pathologic lesion that created it. Arthroscopic excision also avoids much of the morbidity of the open approach and allows intra-articular pathology to be addressed concomitantly. This point has been emphasized by other investigators also. Furthermore, because of the limited surgical dissection, rehabilitation is able to begin earlier, with less patient discomfort and more prompt return to normal activities.

Arthroscopy↗
PubMed1998

Shoulder impingement syndromes.

OBJECTIVE: Not all shoulder pain conditions are a consequence of rotator cuff injuries secondary to anterior subacromial impingement. Additional causative forms have been identified and classified as posterosuperior glenoid rim, subcoracoid and suprascapular nerve (at spinoglenoid notch) impingement syndromes. MATERIAL AND METHODS: We reviewed 206 consecutive magnetic resonance examinations carried out with conventional T1- and T2-weighted spin-echo and gradient-echo sequences in patients complaining of shoulder pain. Adjunctive sequences were acquired with the involved arm positioned in abduction and external rotation. RESULTS: Anterior subacromial impingement is only one of the possible causes of shoulder disorders. Posterosuperior glenoid rim impingement is the most frequent cause of shoulder pain in young throwers. Subcoracoid and spinoglenoid notch suprascapular nerve impingement are additional forms that must be considered in the differential diagnosis because of their frequent occurrence in routine clinical practice. CONCLUSION: Magnetic resonance imaging is the most useful diagnostic modality for shoulder disorders.

Disease Progression↗
PubMed1999

Complications of shoulder dislocation.

Dislocations of the shoulder are the most common joint dislocations seen in the emergency department, and complications of shoulder dislocations are more frequent than is generally believed. It is vital that emergency physicians have current knowledge of complications associated with shoulder dislocations because of their important role in recognition and prevention. Delayed recognition of complications can have an impact on the long-term outcome of patients. Prompt recognition and follow-up are essential. Most references address reduction methods rather than recognition of specific complications. Emergency physicians have few opportunities to update their knowledge of complications of shoulder dislocations. This article briefly reviews mechanisms of shoulder dislocation and discusses complications in light of the mechanisms of injury.

Biomechanical Phenomena↗