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PubMed2000

Shockwave application in calcifying tendinitis of the shoulder--prediction of outcome by imaging.

This prospective study examined 62 patients (65 shoulders) with chronic courses of calcifying tendinitis of the shoulder before and after low-energy extracorporeal shockwave application (ESWA) in order to identify variables associated with the outcome of this treatment. Before ESWA, radiographs and contrast-enhanced magnetic resonance imaging (MRI) of the affected shoulders were obtained in order to document the size and morphology of the calcifications and the contrast media reactions in areas of interest (deposit, synovia, bursae), respectively. In addition, a clinical evaluation was performed. After ESWA (mean follow-up 18.2 months), clinical evaluations of all 65 shoulders revealed an increase in the Constant score from 44% to 78% (p < 0.0001). While size (p = 0.61) and morphology (p = 0.7) of the deposits before ESWA were not associated with the clinical outcome, negative contrast reactions around the deposits (p) = 0.0001), synovia (p = 0.0049) and bursae (p < 0.01) were associated with improved clinical outcomes. After the total study group was divided into two groups, one with Constant scores > or = 75% (n = 43) and the other with scores < 75% (n = 22), the positive predictive value (ppv), specificity (sp) and sensitivity (se) were determined for the negative reaction around the deposit (ppv: 0.94; sp: 0.95; se: 0.38), synovia (ppv: 0.84; sp: 0.82; se: 0.49) and bursae (ppv: 0.86; sp: 0.86; se: 0.44). In 5 cases (7.7%), surgery of the affected shoulder during the follow-up period was performed. No major side-effects were seen in the study group. In conclusion, our results suggest that in patients with chronic calcifying tendinitis, the absence of contrast enhancement, especially around the deposit, is a strong predictive parameter of a positive clinical outcome of ESWA.

Adult↗
PubMed2002

Risk factors for neck-shoulder and wrist-hand symptoms in a 5-year follow-up study of 3,990 employees in Denmark.

OBJECTIVES: A prospective follow-up study of employees in Denmark was analyzed in order to investigate the association between physical and psychosocial exposures and musculoskeletal symptoms in the neck-shoulder and wrist-hand regions. METHODS: Data were derived from a 5-year follow-up questionnaire study of a sample of employees in Denmark, aged between 18 and 59 years. Occupational and individual background factors were assessed in 1990, and the associations with symptoms in 1995 were analyzed using logistic regression. The analysis was restricted to comprise employees free of symptoms in 1990. The neck-shoulder and wrist-hand analyses included 1,895 and 3,179 employees, respectively. RESULTS: Among men, neck-shoulder symptoms were predicted by twisting or bending (odds ratio (OR) 1.5, 95% confidence interval (CI) 1.01-2.26) and social support at work (OR 1.8, CI 1.24-2.50 for low versus rather high social support, OR 1.4, CI 1.00-2.09 for high versus rather high social support). Furthermore, an interacting effect of heavy lifting and sedentary work was indicated. Symptoms in the wrist-hand region were predicted by stress symptoms (OR 1.7, CI 1.12-2.71) and twisting or bending (OR 1.7, CI 1.18-2.57). For women, smoking habits predicted neck-shoulder symptoms (OR 1.8, CI 1.14-2.82, former versus never smokers). Symptoms in the wrist-hand region were predicted by stress symptoms (OR 1.7, CI 1.16-2.41) and twisting or bending (OR 1.9, CI 1.34-2.80). CONCLUSION: The results confirm that physical exposures at work influence the development of musculoskeletal symptoms in the neck-shoulder and wrist-hand regions. However, the results also suggest that a psychosocial exposure (social support) and perceived stress symptoms influence musculoskeletal symptoms.

Adolescent↗
PubMed1998

Worsening of neck and shoulder complaints in humans are correlated with frequency parameters of electromyogram recorded 1-year earlier.

The aim was to investigate whether output and electromyogram (EMG) variables obtained from an isokinetic endurance test of the shoulder flexor muscles of 23 women with neck and shoulder problems in a car and truck industry correlated with improvement or worsening of complaints 1 year later. Each subject performed 100 maximal isokinetic shoulder forward flexions at 60 degrees x s(-1). Surface EMG of the trapezius, deltoid, biceps brachii and infraspinatus muscles and mechanical output (peak torque) were determined for each contraction. The EMG was used to determine mean frequency fmean and the ratio between the signal amplitudes of the EMG of the passive relaxation and active flexion parts of each contraction cycle (SAR). The subjects also rated the degree of fatigue they experienced throughout the test. The magnitude of the shift in fmean was correlated with whether improvement or worsening occurred for complaints in the neck and or shoulders; a significant relationship (r2 = 0.44; P = 0.001) existed between the total frequency shift of the four muscles and the variables measuring improvement in complaints. In the multivariate predictions other fmean variables and perception of fatigue were also of significance. The present study would indicate that a high degree of fmean shift correlates with improvement in neck and shoulder complaints 1 year later. One possible reason could be that fmean reflects the muscle morphology and/or a pathological situation for the type-1 muscle fibres.

Adult↗
PubMed2005

Arthroscopic treatment for septic arthritis of the shoulder in an infant.

We report a case of septic arthritis in the shoulder of an infant treated with a combination of arthroscopic irrigation, debridement, and synovectomy. The results were encouraging. The patient was a boy who was 2 years 6 months of age. His first symptoms were a body temperature of 40 degrees C and right upper arm pain. Five days after the onset, he was brought to our institution. His shoulder was swollen and erythematous. Yellowish fluid (7 ml) was aspirated from his shoulder joint; the causative organism was group A Streptococcus. On admission, arthroscopic surgery was performed. His temperature gradually decreased, and inflammatory markers including the white blood cell count and C-reactive protein level improved. At his 1-year follow-up there was no sign of infection, and a full range of motion in the shoulder was maintained. The interval between the onset and the start of treatment is an important factor affecting the prognosis. The patient was brought to our institution 5 days after onset and underwent arthroscopic surgery on the same day. This early treatment was one of the factors that contributed to a successful result. Arthroscopic surgery, including irrigation and debridement, may be one of the options for treating septic arthritis of an infant's shoulder.

Arthritis, Infectious↗
PubMed1999

Management of the stiff shoulder.

Shoulder stiffness occurs as a result of (1) contractures of the intraarticular capsule or muscle-tendon units or (2) adhesions within the extraarticular humeroscapular or scapulothoracic motion interface. These contractures or adhesions may occur independently or in combination. A thorough history and physical examination usually reveal the diagnosis (idiopathic frozen shoulder or posttraumatic stiff shoulder) and the anatomical locations of fibrosis that is causing stiffness, and identifies other treatable conditions associated with shoulder stiffness (such as diabetes). A gentle home program of passive stretching is effective in most patients. When the home program is not effective, a manipulation or surgical release may be indicated. If manipulation is not effective, capsular contractures are best released arthroscopically as this allows circumferential release without damaging the rotator cuff and thus allows rehabilitation without the need to protect the rotator cuff. The humeroscapular motion interface adhesions can be released either open or arthroscopically, but we believe that an open release combined with an arthroscopic capsular release is quicker and does not interfere with rehabilitation. When necessary, operative management coupled with an aggressive rehabilitation program can provide significant relief of pain and restoration of shoulder motion. Approximately 90% of patients can expect a good result with this treatment algorithm.

Algorithms↗
PubMed1994

Comparing clinician-applied loads for routine, difficult, and shoulder dystocia deliveries.

OBJECTIVE: Our goal was to examine and compare clinician-applied loads during simulated vaginal delivery. STUDY DESIGN: We developed a birthing model and a microcomputer data acquisition system and used them to measure clinician-applied extraction forces, moment, and rates for three perceived categories of delivery. In 39 experiments, clinicians simulated delivery of the fetal shoulders during vaginal delivery for routine, difficult, and shoulder dystocia deliveries. RESULTS: Clinicians averaged 84 N combined force and 473 N-cm neck-bending moment for routine deliveries, 122 N and 697 N-cm for difficult deliveries, and 163 N and 700 N-cm for shoulder dystocia deliveries (p < 0.002). No force or moment parameter was associated with clinician gender or experience. Force levels exceeding 100 N are reached for many clinicians (74% and 82%) for difficult and shoulder dystocia deliveries and for some clinicians (31%) for routine deliveries (p < 0.0001). CONCLUSION: We conclude that simulating shoulder dystocia in the laboratory may be useful in measuring extraction forces and neck-bending moment and that birthing models can be used to train clinicians in force, moment, and rate perception.

Delivery, Obstetric↗
PubMed1987

Biomechanical model of the human shoulder--I. Elements.

In a first step of a biomechanical modelling of the human shoulder the points of application of muscle forces to the bones were determined in a dissection study on four human shoulder specimens. A kinematic description of the shoulder was presented employing bone fixed coordinate systems. Actions of the shoulder muscles were modelled as a system of forces acting along ideal strings. The shoulder complex was treated as a three rigid body twelve degrees of freedom system.

Biomechanical Phenomena↗
PubMed1990

Glenohumeral muscle force and moment mechanics in a position of shoulder instability.

The three-dimensional orientation of the shoulder girdle musculature was studied in five cadaver shoulders in the position of function at 90 degrees of abduction and 90 degrees of external rotation using a method of computer assisted gross muscle cross-section analysis. The muscle volume, muscle fiber length, and physiological cross-sectional area were obtained by dissecting two specimens. The line of action, the magnitude and orientation of the moment were calculated for each muscle crossing the shoulder joint. The quantitative description of the moment potential of muscle forces influencing shoulder function was thus obtained. The most effective flexors of the shoulder which also appear to resist anterior dislocation in the position studied are the pectoral, the short head of the biceps, coracobrachialis, anterior deltoid, and the subscapularis. Most of the rotator cuff muscles and the posterior deltoid acted as adductors, while the anterior deltoid, long and short head of the biceps, and supraspinatus were abductors. In this position, external rotation was effected by the long head of the biceps, coracobrachialis, and the posterior deltoid, while the majority of the remaining muscles acted as internal rotators.

Aged↗
PubMedDate not supplied

Management of anticipated and actual shoulder dystocia. Interpreting the literature.

Shoulder dystocia is a rare but serious obstetric complication that can result in significant neonatal and maternal morbidity and in costly litigation. Conflict exists in the literature regarding definition, incidence, predictability and preventability, relationship to neonatal injury, and appropriate management models. Anticipatory clinical interventions for potential shoulder dystocia have included ultrasound assessment of macrosomia; elective induction of labor; elective caesarean section; altered place of birth; and generous episiotomy/episioproctotomy. The authors note that these interventions often conflict with client desires and nurse-midwifery philosophy of birth, generate significant risks and costs in themselves, and do not address the poor predictability of shoulder dystocia. In recent literature, the safety and efficacy of maternal position change maneuvers (such as McRoberts maneuver, hands-knees position, and squatting) have been presented as methods to resolve most cases of shoulder dystocia. Despite the success of these more benign, external maneuvers, the episiotomy mandate remains in nearly all obstetric and midwifery texts and handbooks (1-8) and journal references (9-19). A literature review of related professional disciplines was undertaken to study these conflicts and to identify support for applying a philosophy of minimal, appropriate intervention to the complex issue of shoulder dystocia.

Delivery, Obstetric↗
PubMed1989

Arthroscopic versus nonoperative treatment of acute shoulder dislocations in young athletes.

We evaluated the natural history of anterior shoulder dislocations in a young athletic population (cadets at the United States Military Academy) and compared conventional means of nonoperative treatment with early arthroscopic treatment (staple capsulorraphy or anterior glenoid abrasion). The rate of recurrent instability after a shoulder dislocation was 92% (35 of 38) in cadets treated nonoperatively. Strict adherence to a supervised nonoperative treatment program had no effect on the recurrence rate. All recurrences of instability occurred within 14 months of the initial injury. In comparison, arthroscopic treatment of acute shoulder dislocations has been successful thus far in 78% (7 of 9) of cadets followed for at least 14 months. With the high rate of recurrence of shoulder instability in young athletes, we believe that arthroscopic surgical intervention after the initial shoulder dislocation can dramatically lower the recurrence rate and should be considered as a treatment option in young athletes.

Adolescent↗
PubMed1990

SLAP lesions of the shoulder.

A specific pattern of injury to the superior labrum of the shoulder was identified arthroscopically in twenty-seven patients included in a retrospective review of more than 700 shoulder arthroscopies performed at our institution. The injury of the superior labrum begins posteriorly and extends anteriorly, stopping before or at the mid-glenoid notch and including the "anchor" of the biceps tendon to the labrum. We have labeled this injury a "SLAP lesion" (Superior Labrum Anterior and Posterior). There were 23 males and four females with an average age of 37.5 years. Time from injury to surgery averaged 29.3 months. The most common mechanism of injury was a compression force to the shoulder, usually as the result of a fall onto an outstretched arm, with the shoulder positioned in abduction and slight forward flexion at the time of the impact. The most common clinical complaints were pain, greater with overhead activity, and a painful "catching" or "popping" in the shoulder. No imaging test accurately defined the superior labral pathology preoperatively. We divided the superior labrum pathology into four distinct types. Treatment was performed arthroscopically based on the type of SLAP lesion noted at the time of surgery. The SLAP lesion, which has not been previously described, can be diagnosed only arthroscopically and may be treated successfully by arthroscopic techniques alone in many patients.

Accidental Falls↗
PubMed2005

Assessment of shoulder impairment after functional neck dissection: long term results.

OBJECTIVE: In this prospective study, we attempted to use objective techniques to measure shoulder disability and evaluate patients who underwent functional neck dissection (FND) procedure. Patients were compared on the basis of preoperative and postoperative range of motion (ROM) measurements, pain and stiffness domains. At the final visit, a Neck Dissection Impairment Index (NDII) questionnaire was applied to all patients. METHOD: Twenty-five patients treated with head and neck cancer who underwent bilateral FND simultaneously with the resection of primary tumor enrolled in this study from April 2001 to July 2004. Flexion, extension, abduction, internal and external rotations of the shoulder have been measured with electronic incliometer preoperatively, and at the 1st, 3rd, 6th, and 18th months postoperatively. A questionnaire modified from neck dissection impairment index was applied to all patients to measure neck and shoulder disability at final visit. Pain and stiffness domains were also assessed preoperatively and at postoperative 18th month. RESULTS: Measurements of abduction at the first and third months were found to be decreased in comparison with preoperative measurements. These differences were statistically significant (p<0.05). The pain and stiffness scores of all patients at the final visit were significantly worse than the preoperative scores (p<0.005). At the final visit NDII of patients who underwent total laryngectomy were significantly worse than of the patients who underwent partial laryngectomy and glossectomy (p=0.002 and 0.043, respectively). All these results did not correlate with age, radiation therapy (RT), operation side, T stage. CONCLUSION: FND is oncologicaly safe procedure and gives rise to less shoulder morbidity. Although, ROM improved after 18 months from surgery, pain and stiffness were found to be worse than preoperative values. The patients with total laryngectomy had lower NDII scores regarding to other patients. Therefore, shoulder disability can be attributed not only to neck dissection but also to primary surgery.

Aged↗
PubMed2005

Scapular positioning in patients with shoulder pain: a study examining the reliability and clinical importance of 3 clinical tests.

OBJECTIVE: To examine the interobserver reliability, internal consistency, and clinical importance of 3 clinical tests for the assessment of scapular positioning in patients with shoulder pain. DESIGN: Prospective repeated-measures design. SETTING: Private practices for physical therapy and hospital outpatient physical therapy divisions. PARTICIPANTS: Twenty-nine patients with shoulder pain who were diagnosed by a physician as having a shoulder disorder. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Study participants filled in a visual analog scale for pain and the Shoulder Disability Questionnaire. Next, 2 assessors performed the following tests: measurement of the distance between the posterior border of the acromion and the table, measurement of the distance from the medial scapular border to the fourth thoracic spinous processes, and the lateral scapular slide test. RESULTS: The interobserver reliability coefficients were greater than .88 (intraclass correlation coefficients) for the measurement of the distance between the posterior border of the acromion and the table, were greater than .50 for the measurement of the distance from the medial scapular border to the fourth thoracic spinous processes, and were greater than .70 for the lateral scapular slide test. The Cronbach alpha coefficient for internal consistency for all tests was .88. No associations between the outcome of the tests and self-reported pain severity or disability were found. CONCLUSIONS: These data provide evidence favoring the interobserver reliability of 2 of 3 tests for the assessment of scapular positioning in patients with shoulder pain. The clinical importance of the tests' outcomes, however, is questionable.

Adolescent↗
PubMed2006

Electromyographic activity in the immobilized shoulder girdle musculature during scapulothoracic exercises.

OBJECTIVE: To quantify the electromyographic activity in the shoulder girdle musculature during scapulothoracic exercises performed in a shoulder immobilizer in asymptomatic men. DESIGN: Descriptive. SETTING: Motion analysis laboratory at a tertiary care center. PARTICIPANTS: Five asymptomatic male volunteers ages 24 to 32 years. INTERVENTION: Fine-wire (supraspinatus, infraspinatus, upper subscapularis) and surface (deltoids, trapezii, biceps, serratus anterior) electrodes recorded electromyographic activity from each muscle during scapular clock, elevation, depression, protraction, and retraction exercises completed during a single testing session in random order. MAIN OUTCOME MEASURE: Mean peak normalized (percentage of maximal voluntary contraction [MVC]) electromyographic activity of each muscle during each exercise. RESULTS: Biceps activity was uniformly low (<20% MVC), whereas upper subscapularis activity was uniformly high (40%-63% MVC). Both scapular depression and protraction elicited low activity (<20% MVC) in the supraspinatus, infraspinatus, anterior deltoid, and biceps brachii muscles, while generally producing greater than 20% MVC activity in the trapezii and serratus. Scapular depression produced the largest serratus anterior activity (47% MVC). CONCLUSIONS: These data are the first to describe the electromyographic activity during scapulothoracic exercises while in a shoulder immobilizer. Based on electrophysiologic data in normal volunteers, our findings suggest that during periods of shoulder immobilization: (1) scapular depression and protraction exercises could potentially be safely performed after rotator cuff repair to facilitate scapulothoracic rehabilitation, (2) all exercises studied could potentially be safe after superior labral anteroposterior shoulder repair, and (3) all exercises studied should be avoided after subscapularis repair. Further investigation in symptomatic individuals may facilitate refinement of these recommendations.

Adult↗
PubMed2003

Thromboembolic complication after arthroscopic shoulder surgery.

Thromboembolic complications after arthroscopic shoulder surgery are very unusual and need thorough investigation of the possible origin. In this case of venous pulmonary thromboembolism after arthroscopy of the shoulder, neither a hint of coagulopathy nor an anatomic abnormality could be found that explains this complication. Therefore, irritation of the subclavian vein caused by compression by the motor-driven shaver is probably one cause for our thromboembolic complication. Careful attention to positioning, fluid management, and use of traction, as well as an appreciation of shoulder anatomy to select portal placement will help decrease the common complications associated with shoulder arthroscopy. A further option to prevent thrombembolic complications in shoulder arthroscopy patients might be prophylaxis with a low-weight heparin in patients with risk factors. In conclusion, awareness of uncommon complications such as deep venous thrombosis and pulmonary embolism will help the orthpaedic surgeon promptly diagnose and treat these problems.

Anticoagulants↗
PubMed2006

Shoulder instability and related rotator cuff tears: arthroscopic findings and treatment in patients aged 40 to 60 years.

PURPOSE: To report our experience with the arthroscopic treatment of patients aged 40 to 60 years with rotator cuff lesions, shoulder instability, or both, and to seek a relationship among capsular-labral complex lesions, cuff tears, number of dislocations, and patient age. TYPE OF STUDY: Case series. METHODS: From January 2000, all patients aged between 40 and 60 years undergoing an arthroscopic procedure for rotator cuff lesions, shoulder instability, or both were divided into 3 cohorts: shoulder instability (group I), complete cuff tear (group C), and instability and complete cuff tear (group IC). In May 2002 there were 50 patients per group. Arthroscopic findings were analyzed using the Pearson correlation coefficient and the chi2 test to seek correlations between the lesions. The Student t test was used to highlight significant differences between preoperative and postoperative scores. RESULTS: There was a strong correlation between the rising number of dislocations and associated lesions of the supraspinatus and infraspinatus (P < .001); this correlation became stronger after 7 episodes of dislocation (P < .0001). There was no correlation between capsular or Bankart lesion and presence or absence of rotator cuff tears (P > .5). Two cases of recurrence of instability were recorded in group IC. Postoperatively, the Constant and Rowe scores rose significantly and consistently in all patients (P < .001). CONCLUSIONS: Rotator cuff tears and glenohumeral instability appear to be closely related. Patient age and number of dislocations do not appear to correlate with Bankart or capsular lesions, whereas posterosuperior cuff tears seem to be influenced by number of dislocations. Although data do not permit us to conclude whether repair of the sole cuff tear can achieve shoulder stability nor whether shoulder stabilization alone can resolve the instability, treatment of both lesions should be performed arthroscopically. LEVEL OF EVIDENCE: Level IV, case series.

Adult↗
PubMed2006

Decreasing glenoid inclination improves function in shoulders with simulated massive rotator cuff tears.

BACKGROUND: A massive rotator cuff tear leads to poor shoulder function as evidenced by diminished glenohumeral abduction and superior translation of the humeral head compared to its normal position. The inclination angle of the glenoid has been associated with rotator cuff tears. The objective of this study was to quantify the effect of a decreased glenoid inclination angle on glenohumeral kinematics during active abduction in shoulders with a simulated, massive rotator cuff tear. METHODS: Eight fresh-frozen full upper extremities were tested using a dynamic shoulder testing apparatus. After recording the kinematics of the intact shoulder, a massive rotator cuff tear was surgically simulated. An osteotomy of the glenoid was then performed and the inclination angle was decreased by 30 degrees . The translation of the humeral head during abduction and the maximum abduction angle were recorded. FINDINGS: With an intact rotator cuff minimal humeral head translation on the glenoid occurred and the maximum abduction angle was mean 85.5 degrees (SD 7.4 degrees ). A massive rotator cuff tear resulted in superior translation of the humeral head with impingement on the acromion. The maximum abduction angle was mean 15.5 degrees (SD 9.4 degrees ). Decreasing the inclination angle of the glenoid resulted in a significant reduction of superior humeral head translation during abduction and there was no impingement on the acromion. The maximum abduction achieved was mean 28.5 degrees (SD 17.0 degrees ). INTERPRETATION: From a clinical perspective the reduced superior translation may decrease shoulder pain since the humeral head no longer impinges on the acromion. Further investigations are necessary to assess if the improvement in abduction is clinically significant.

Cadaver↗
PubMed2006

A simple classification system was recommended for patients with restricted shoulder or neck range of motion.

OBJECTIVE: To construct an empirical classification of patients with shoulder complaints, and then to investigate the relationship between the empirical classification and the setting in which the patients were recruited, their demographic and clinical characteristics, and the original diagnostic categories. STUDY DESIGN AND SETTING: A latent class analysis was performed on the combined data of two previous studies. RESULTS: Four clusters of patients emerged, one with patients who have a small chance of any restriction of the motion of the shoulder and a moderate chance of restriction of the motions of the neck, a second with patients who have a high chance of restriction of the motions of the shoulder and a moderate chance of restriction of motions of the neck, a third with patients who have a low to moderate chance of restriction of all motions, and a fourth with patients who have a high chance of restriction of all of the motions. Patients recruited from a clinic for rheumatology and rehabilitation and from the orthopedic clinic were more present in the second cluster. Patients in the third cluster were on average younger than those in the other clusters. There appeared to be little agreement between the clusters found and the classification of patients according to the original diagnostic categories. CONCLUSION: Patients experiencing shoulder pain can be classified in a simple way into four categories, reflecting the distinction between problems of the shoulder and those of the neck. A simple classification rule is proposed with which almost all patients can be classified into the four clusters.

Adolescent↗