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Muscle coordination and choice-reaction time tests as indicators of occupational muscle load and shoulder-neck complaints.

The use was explored of psychomotor tests as indicators of the risk of shoulder-neck disorders in workers with low-level static loads on the shoulder muscles. Two groups of workers performing office work and light production work were studied. A muscle coordination test with continuous movement of the arm and hand between three target areas and a psychogenic tension test, posing mental demands and with minimal requirement for body movements, aimed to quantify muscle activity in excess of that needed for biomechanical purposes. The electromyogram (EMG) recording of the active trapezius muscle in the muscle coordination test correlated with the median and static EMG values of the vocational (i.e. during the normal work task) trapezius recording both for the office and production workers, but showed no correlation with shoulder-neck complaints. The EMG responses in the psychogenic tension test and of the passive (contralateral) trapezius in the muscle coordination test correlated best with the parameters showing short, spontaneous pauses in the EMG recording of occupational load. For the office workers, but not for the production workers these parameters also correlated with shoulder-neck complaints and the presence of psychosocial problems. Psychomotor tests may thus be useful as indicators of the risk of shoulder-neck complaints in certain occupations, but further experimentation is needed to validate this conclusion.

Adult↗

Occupational musculoskeletal stress and disorders of the neck and shoulder: a review of possible pathophysiology.

Disorders and complaints in the neck and shoulder regions are common among industrial workers and are often attributed to occupational musculoskeletal stress. The possible pathophysiological mechanism of occupational stress on the neck and shoulders is reviewed. A mechanical origin for cervical disc degeneration and osteoarthrosis is reported for a few occupational groups. However, a mechanical origin for osteoarthrosis is debatable. A work posture involving elevated arms may accelerate degeneration of shoulder tendons through impairment of circulation due to static tension and humeral compression against the coracoacromial arch. Furthermore, work tasks with repetitive arm movements may evoke shoulder tendinitis or tendo-vaginitis, probably due to friction. Three possible routes to neck-shoulder muscular pain are discussed; mechanical failure, local ischemia and energy metabolism disturbance.

Bone Diseases↗

Contracture of the shoulder joint.

The movements of the shoulder joint may sometimes be markedley limited due to posttraumatic or inflammatory changes in the shoulder joint or in adjacent organs, a condition designated as contracture of the shoulder joint or frozen shoulder. The routine treatment consists of positioning the arm as often as possible in abduction, and of diligent active and passive mobilization exercises. In those patients who started the treatment after a long delay so that the articular as well as the periarticular tissues were very shrunken, manipulation of the shoulder joint was carried out under general anesthesia this led to the return of full motion of the joint in the great majority of these patients. However, in those patients who did not benefit by manipulation, surgical revision of the joint and of periarticular structures was carried out for excision of all scarified tissues. The result was restoration of the mobility of the joint to an adequate although not total range.

Adult↗

The relationship between contraction and relaxation during fatiguing isokinetic shoulder flexions. An electromyographic study.

Knowledge of the strength, endurance and coordination of the shoulder muscles during dynamic contractions in healthy women would contribute to the understanding of symptoms in that part of the body in patients with myalgia. Twenty clinically healthy women performed single maximal forward shoulder flexions at four different angular velocities (0.57-3.14 rad.s-1). The same subjects also took part in two endurance tests (at angular velocities of 0.57 and 2.09 rad.s-1, respectively) consisting of 150 repeated maximal shoulder flexions. Electromyographic activity (EMG) was registered from four shoulder flexors using surface electrodes. Work was used as the mechanical variable. During the endurance tests subjects rated their perception of fatigue in the shoulder muscles. Work and the amplitude of the EMG signals decreaesd with angular velocity. The mean power frequency of the EMG was constant in the span of angular velocities investigated. During the endurance tests, work and the mean power frequency decreased during the initial 40-60 contractions followed by stable levels. The relative work level was higher at 2.09 than at 0.57 rad.s-1. Greater relative increases of the signal amplitudes of EMG occurred at 2.09 than at 0.57 rad.s-1. The EMG activity between the flexions (during the supposed passive extension) was higher at 2.09 than at 0.57 rad.s-1. Such a high activity was associated with a low mechanical performance at 2.09 rad.s-1. It is suggested that the initial sharp decreases in work and in mean power frequency reflect the fatiguing of the fast twitch motor units. Dynamic work consisting of continuous activity could predispose to muscle complaints.

Adult↗

Arm-movement-related neurons in the primate superior colliculus and underlying reticular formation: comparison of neuronal activity with EMGs of muscles of the shoulder, arm and trunk during reaching.

Neuronal activity was recorded from the superior colliculus (SC) and the underlying reticular formation in two monkeys during an arm reaching task. Of 744 neurons recorded, 389 (52%) clearly modulated their activity with arm movements. The temporal activity patterns of arm-movement-related neurons often had a time course similar to rectified electromyograms (EMGs) of particular muscles recorded from the shoulder, arm or trunk. These reach cells, as well as the muscles investigated, commonly exhibited mono- or biphasic (less frequently tri- or polyphasic) excitatory bursts of activity, which were related to the (pre-)movement period, the contact phase and/or the return movement. The vast majority of reach cells exhibited a consistent activity pattern from trial to trial as did most of the muscles of the shoulder, arm and trunk. Similarities between the activity patterns of the neurons and the muscles were sometimes very strong and were especially notable with the muscles of the shoulder girdle (e.g. trapezius descendens, supraspinatus, infraspinatus or the anterior and medial deltoids). This high degree of co-activation suggests a functional linkage, though not direct, between the collicular reach cells and these muscles. Neuronal activity onset was compared with that of 25 muscles of the arms, shoulders and trunk. The majority of cells (78.5%) started before movement onset with a mean lead time of 149+/-90 ms, and 36.5% were active even before the earliest EMG onset. The neurons exhibited the same high degree of correlation (r=0.97, Spearman rank) between activity onset and the beginning of the arm movement as did the muscles (r=0.98) involved in the task. The mean neuronal reach activity (background subtracted) ranged between 7 and 193 impulses/s (mean 40.5+/-24.2). The mean modulation index calculated [(reach activity background activity)/reach activity+background activity)] was 0.75+/-0.23 for neurons (n=358) and 0.87+/-0.14 for muscles (n=25). As the monkeys fixated the reach target constantly during an arm movement, neuronal activity which was modulated in this period was not related to eye movements. The three neck muscles investigated in the reach task exhibited no reach-related activity modulation comparable to that of either the reach cells or the muscles of the shoulder, arm and trunk. However, tonic neck muscle EMG was monotonically related to horizontal eye position. The clear skeletomotor discharge characteristics of arm-movement-related SC neurons revealed in this study agree with those already known from other sensorimotor regions (for example the primary motor, the premotor and parietal cortex, the basal ganglia or the cerebellum) and are consistent with the possible role of this population of reach cells in the control of arm movements.

Animals↗

[Shoulder prostheses].

The design of shoulder prostheses has been developed through four generations which mirror adaptation to our increasing knowledge of the biomechanics of the shoulder joint. Modern shoulder prostheses are adapted to the size, inclination, posterior offset, and retrotorsion of the shoulder. The main reasons for implantation of a shoulder prosthesis are primary osteoarthritis, posttraumatic and rheumatoid arthritis, avascular necrosis, instability arthritis and cuff defect arthropathy. Typical implants are cup prostheses for surface replacement, anatomical stem prostheses, and reverse prostheses. Total prostheses are functionally better as soon as the arthritis involves the glenoid, whereas hemiprostheses should be preferred as long as the glenoid is intact. The stem is mostly cemented, whereas in younger patients with good bone quality a cementless stem may be used. Cemented glenoids may be considered as standard.

Arthritis, Rheumatoid↗

[Results of posterior inferior capsular shift in posterior shoulder instability].

PURPOSE: The purpose of this study was the evaluation of our results after posteroinferior capsular shift in patients with a posterior shoulder instability. MATERIALS AND METHODS: In a prospective study we evaluated 12 patients (14 shoulder joints) with recurrent posterior shoulder dislocations who were stabilized by a posteroinferior capsular shift procedure. For the clinical documentation the Rowe-Score, the ASES-Score and the SF-36 were used. Furthermore the patients were submitted to standardized EMG-, isokinetic and proprioceptive tests. RESULTS: After an average follow-up of 22.2 months there were two recurrences which occurred during the first postoperative year. The Rowe-Score improved from 46.25 to 76.34 points. The ASES-Score showed an average of 42.43 points pre-operatively and at the time of follow-up an average of 78.86 points. Most parameters of the ASES-Score as well as the score in total had a constant positive tendency. Only the subjective rating of stability showed a slight decrease after the first six months due to the two redislocations. But even the stable shoulder joints demonstrated limitations when throwing a ball. The SF-36 showed a definite gain in the overall quality of living as well. The EMG-tests at follow-up showed a deficit for the patients compared with a control group; even more for the female than for the male patients. Similar tendencies were found with the isokinetic strength. The proprioception did not show any differences between the patients and the control group. CONCLUSION: With adequate patient selection and after failure of all possible conservative treatments the posteroinferior capsular shift is a therapeutical option in recurrent posterior shoulder instability.

Adolescent↗

[Shoulder dislocation in the newborn. Report of 12 cases and review of the literature].

Shoulder dislocation in the newborn is a rare entity. Therefore, a therapeutic regimen does not exist. This retrospective clinical study (1967-2003) includes 9 newborns with 12 dislocations of the shoulder. The data focus in particular on the therapeutic strategy and its success. The position of the joint and its functionality were monitored with a questionnaire. Publications from 1904 to 2003 were reviewed and served for comparison. Results of calculations showed that 0.018-0.07% of newborns suffer from shoulder dislocations. The diagnosis was made on average at the age of 22 days. Our data include four cases each of congenital and paralytic and two cases each of spastic and traumatic shoulder dislocations. All of them were initially treated conservatively, but because of inadequate results one patient finally had to be operated. In the follow-up of 19.4 years, none of them developed a redislocation and all shoulder functions were suitable for daily life. We propose that patients primarily be treated conservatively; however, if therapy fails, surgery has to be performed.

Birth Injuries↗

[100 years shoulder and elbow surgery].

Within the past 100 years, shoulder and elbow surgery has developed into a highly sophisticated specialty. Technical advancements now allow operative treatment of most shoulder and elbow disorders. Shoulder arthroplasty is able to accurately reproduce normal anatomy and function. It is used in degenerative omarthrosis, humeral head fractures, rheumatoid arthritis, and rotator cuff arthropathy. After 10 years, survival of 93% can be expected and in omarthrosis an outcome score of 85 of 100 points. In recurrent shoulder instability, open surgery is still the gold standard. It allows to accurately adjust capsular tension. Modern arthroscopic techniques shorten the capsule with sutures or by capsular shrinkage, but sufficient follow-up is not yet available. Arthroscopic subacromial decompression is the standard procedure for subacromial disorders. The indication for operative rotator cuff closure must be adjusted to the age and functional expectations of the patient. Smaller defects can be closed arthroscopically. The operative technique in proximal humerus fractures is particularly demanding, due to osteoporosis and the risk of avascular necrosis. Magnetic resonance imaging is the preferred imaging technique at the shoulder, often combined with intravenous or intra-articular contrast injection. Elbow joint replacement is mostly used in rheumatoid arthritis and has achieved a high technical standard.

Arthroscopy↗

Sclerosing polidocanol injections to treat chronic painful shoulder impingement syndrome-results of a two-centre collaborative pilot study.

The histological changes found in the supraspinatus tendon have similarities with the findings in Achilles-, patellar- and extensor carpi radialis brevis (ECRB)-tendinopathy. In recent studies, we have found a vasculo-neural ingrowth in chronic painful Achilles and patellar tendinopathy, and demonstrated good short-term clinical effects with injections of the sclerosing substance polidocanol. In this collaborative two-centre pilot study, 15 patients (10 males and 5 females, mean age 46 years) with a long duration of shoulder pain (mean 28 months), and given the diagnosis chronic painful shoulder impingement syndrome, were included. They had tried rest, traditional rehabilitation exercises and multiple subacromial corticosteroid injections, without effect. We found vascularity (neovessels) in chronic painful, but not in pain-free, supraspinatus tendons, and prospectively studied the clinical effects of ultrasound (US) and colour Doppler (CD)-guided injections of polidocanol, targeting the area with neovessels. The patients evaluated the amount of shoulder pain during horizontal shoulder activity on a visual analogue scale (VAS), and satisfaction with treatment. Two (median) (range 1-5) polidocanol treatments (with 4-8 weeks in between) were given. In four patients (considered treatment failure), cortisone was injected into an inflamed subacromial bursa at one separate occasion weeks after the last polidocanol injection. At follow-up, 8 (median) (range 4-17) months after the treatment, 14 patients were satisfied with the result. Using the visual analogue scale evaluation (VAS), the pain dropped from 79 before treatment to 21 at follow-up (P < 0.05). In the short-term perspective, sclerosing polidocanol injections targeting the neovessels in the supraspinatus tendon and/or bursa wall seems to have a potential to reduce the pain during shoulder loading activity.

Adult↗

A clinical and radiographic comparison of absorbable and non-absorbable suture anchors in open shoulder stabilisation.

The aim of this study was to compare the clinical and radiographic results using either absorbable or non-absorbable suture anchors in patients with recurrent unidirectional, post-traumatic shoulder dislocations. All patients had a Bankart lesion. One surgeon operated on 33 consecutive patients, 27 males and six females. Group A comprised 15 shoulders and group B 18 shoulders, all of which underwent a standardised open Bankart reconstruction using 3.7-mm TAG suture anchors. In group A, absorbable anchors were used, while in group B, non-absorbable ones were used. There was one re-dislocation in each group. In group A, the Rowe and Constant scores were 89 (69-98) and 89 (76-99) points, respectively. The corresponding values in group B were 87 (44-98) (not significant; NS) and 90 (71-100) points (NS). The strength measurements revealed 8.1 (3.8-12.3) kg in 90 degrees abduction in group A and 10.0 (6.7-12.0) kg in group B. Healthy control shoulders revealed 10.2 (4.5-13.2) kg (NS A and B versus controls). The external rotation in abduction was 70 degrees (40-90) in group A and 80 degrees (40-100) in group B. The value for the controls was 90 degrees (80-120) [P < 0.001 (A versus controls), P < 0.05 (A versus B) and P < 0.001 (B versus controls)]. The radiographs revealed that 9/15 (60%) in group A and 10/15 (66%) in group B had visible drill holes or cystic formations in conjunction with the drill holes (NS). Furthermore, 11/15 (73%) in group A and 10/15 (66%) in group B had signs of minor degeneration (NS). We conclude that, in terms of stability and clinical results, no differences were found between the study groups. Both groups demonstrated a restriction in external rotation as compared with the healthy shoulders in the same cohort. On the radiographs, visible drill holes or cystic formations in conjunction with the drill holes were seen with equal frequency, regardless of whether absorbable or non-absorbable suture anchors were used.

Absorbable Implants↗

Bone scintigraphy screening for osteonecrosis of the shoulder in patients with non-traumatic osteonecrosis of the femoral head.

OBJECTIVE: In patients with non-traumatic osteonecrosis of the femoral head (ONFH), the shoulder is one of the major affected sites secondary to the proximal and distal femur in cases of multiple osteonecrosis. The present study attempted to investigate whether technetium bone scintigraphy is useful for screening of non-traumatic osteonecrosis of the shoulder (ONS). DESIGN AND PATIENTS: A total of 170 shoulder joints in 85 patients with ONFH were evaluated by bone scintigraphy and the findings compared with those of magnetic resonance imaging (MRI). The MR diagnosis was used as the gold standard. RESULTS: Based on the diagnosis by MRI, ONS was detected in 43 shoulders of 27 patients (25%). All necrotic lesions were located in the humeral head. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value of bone scintigraphy for ONS detection were 65%, 81%, 77%, 54% and 87%, respectively. When the necrotic angle of the lesions on the mid-coronal MRI was more than 40 degrees, the sensitivity of bone scintigraphy for ONS detection increased to 88% (21/24 shoulders). CONCLUSION: Bone scintigraphy may be useful for demonstrating medium or large ONS lesions on screening of patients with ONFH.

Adolescent↗

Rapid destructive arthritis of the shoulder.

Rapid destructive arthritis of the shoulder, although uncommon, has received much attention in the recent medical literature. It has been described by several authors under varied names: hemorrhagic shoulder of the elderly, Milwaukee shoulder syndrome, rapid destructive arthritis of the shoulder, apatite-associated destructive arthritis and idiopathic destructive arthritis of the shoulder. This particular form of arthritis affects mainly elderly patients, predominantly women, with limited pain, rotator cuff tear, joint instability, voluminous mildly inflammatory, blood-stained effusion, basic calcium phosphate crystals, and marked joint and bone destruction.

Age Factors↗

A new in vivo technique for three-dimensional shoulder kinematics analysis.

OBJECTIVE: The field of shoulder kinematics research has long relied upon the use of cadaveric models or invasive techniques in human volunteers. In this paper, a novel method is presented that utilizes magnetic resonance imaging (MRI) and a software system called 3DVEWNIX. This method permits non-invasive, repetitive evaluation of living patients for glenohumeral kinematics analysis. The objectives of this study were twofold: to validate the quantitative accuracy of this technique; and to demonstrate glenohumeral relationships in asymptomatic volunteers during internal and external rotation of the arm. DESIGN: The translational accuracy was first assessed by comparing known cadaveric glenohumeral translations with calculations from MR images of the cadaver. Nine asymptomatic volunteers were subsequently placed in an external shoulder positioning device in the scanner and imaged in 10 degrees increments of actively achieved internal and external rotation. Three-dimensional reconstructions of the glenoid and humerus were used to evaluate the glenohumeral relationships in the tested positions of rotation. RESULTS: The quantitative analysis revealed an error of 0.61 mm (SEM 0.11 mm). Examination of the volunteers demonstrated normal relationships about the glenohumeral joint in internal and external rotation. In addition, this method provided detailed images of the bony surface architecture from any perspective. These images can be transformed into a cinematic three-dimensional depiction of active shoulder rotation. CONCLUSION: This new technique offers an accurate, non-invasive method for assessing the normal glenohumeral relationships in shoulder kinematics. We now possess the capability to investigate the kinematics of normal and abnormal shoulder conditions non-invasively in a large patient population.

Adult↗

The role of shoulder fusion in the era of arthroplasty.

The indications, surgical techniques, results and complications of shoulder fusion are described. The indications are bacterial infection, paralytic disorders in infancy, combined deltoid and rotator cuff paralysis, post-traumatic brachial plexus lesions, inflammatory arthritis with severe rotator cuff involvement, failed arthroplasty, recurrent dislocation, after resection of tumours, irreparable rotator cuff tear, painful arthritis in a patient whose activities require power but not movement, the immunocompromised patient, and tuberculosis. Satisfactory results are achieved in children with isolated shoulder paralysis, but in adults loss of glenohumeral movement is associated with about 50% loss of function. The best results are obtained in cases of isolated shoulder paralysis with a normal arm and hand distally. The most frequent complications are nonunion (5-20%), fracture of the ipsilateral humerus (10-15%) and infection (3-5%). Other causes of failure are functional limitation, fusion in malposition, functional involvement of the distal joints, acromioclavicular dislocation, suprascapular traction neuritis, failure or migration of an internal fixation device, epiphyseal problems, and the complications of using an allograft. Shoulder replacement is most likely to be chosen for most destructive shoulder disorders, but fusion is useful in certain cases.

Adult↗

The lateral impaction of the shoulder.

17 patients had radiographic demonstration of injury to the clavicle, scapula and ribs from an impact delivered to the lateral shoulder. The study included 13 males and 4 females whose ages ranged from 18 to 83 years (average 45 years). Most injuries were sustained in falls or motor vehicle accidents. Analysis of these cases suggests a biomechanical hypothesis concerning the transmission of the impact forces within the shoulder girdle. According to this hypothesis, the impaction force applied to the lateral shoulder is transmitted from outside inward following two paths. The anterior and superior path passes through the acromio-clavicular joint, the clavicle, the costo-clavicular joint and the sterno-clavicular joint. The posterior and inferior path is transmitted within the gleno-humeral joint, the scapula and the scapulo-thoracic joint. Major impacting force is required to disrupt the anterior and posterior arches of the shoulder girdle. When both of these supporting structures are damaged, the patient is at risk for more serious injuries, including disruption of the thorax, shoulder joint, brachial plexus and neck.

Accidental Falls↗

A direct comparison of MR images and thin-layer plastination of the shoulder in the apprehension-test position.

Until now, patients with a shoulder instability being examined using magnetic resonance imaging have been placed in a position with the arm adducted or in the ABER position, as a result of the way conventional MR systems are built. Magnetic resonance systems with an open configuration have made it possible, for the first time, to examine patients in the apprehension-test position, which is a representative diagnostic position for anterior shoulder instability. This new examination position requires an exact understanding of layered imaging anatomy in order to clearly identify MR structures. The purpose of this study is to make possible a direct comparison of the respective abilities of MR cross-section imaging and thin-layer plastination to clearly identify all MR structures of the shoulder positioned in the apprehension-test position. The two shoulders of a body donor were separated and stored in special position supports in the apprehension-test position. The magnetic resonance examination was carried out using a vertically open 0.5-T MR system (Signa SP/i, General Electric Medical Systems, Milwaukee, WI). The following sequences were used: 2D GRE, TR 42.5 ms, TE 20 ms, layer width 3 mm, matrix 512x512, FOV 24 cm. The coronary und transversal MR cross-section segments were subsequently planned in conjunction with thin-layer plastination for both shoulders. Using a direct comparison of MR images with the corresponding thin-layer plastination, it was possible to clearly identify all MR structures.

Aged↗

[Technique and diagnostic value of musculoskelatal ultrasonography in rheumatology. Part 5: Ultrasonography of the shoulder].

Shoulder-related symptoms are very common in rheumatic diseases. For the evaluation of the diagnosis as well as for therapy and prognosis, an anatomic assignment is essential. Clinical investigations alone are often not capable to do this. Ultrasonography is a method to delineate bony surfaces as well as the soft tissues around the shoulder joints statically and even dynamically. For the purpose of rheumatic diseases, ultrasound standard scans help to detect the lesions at the biceps tendon, the bursae, the rotator cuff, the humeral head as well as in the acromial and sternoclavicular joints. Considering the limitations of the method (obesity, frozen shoulder, no findings under bony structures) and knowing the pitfalls and errors of the method, ultrasonography is a reliable, quick and low cost method for the diagnosis of rheumatic shoulder joint pathology. Compared to computer tomography and magnetic resonance imaging, ultrasonography should be used as a screening method. The following standard scans are suggested for sonographic evaluation of the shoulder: 1) anterior transverse scan and 2) anterior longitudinal scan at the bicipal groove to detect synovitis and tenosynovitis, 3) anterior transverse scan at the coracoacromiale window in the neutral position, 4) at maximal external rotation and 5) at maximal internal rotation to evaluate the rotator cuff, bursitis, synovitis and erosions, 6) anterior longitudinal scan at 90 degrees to the coracoacomiale window at maximal internal rotation to describe these findings in an additional dimension, 7) anterior-lateral longitudinal scan at the anterior lateral acromion to tuberculum majus to evaluate the distal part of the supraspinatus muscle, 8) posterior transverse scan at the fossa infraspinata lateral under the spina scapulae, 9) axillary longitudinal scan to evaluate synovitis, synovial proliferation, erosions at the humeral head, lesions at the glenoidale labrum, 10) anterior transverse scan at the acromioclavicular joint and 11) anterior oblique scan at the sternoclavicular joint to detect synovitis, synovial proliferation, erosion, osteophytes.

Acromioclavicular Joint↗