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PubMedDate not supplied

Anterior shoulder dislocation in adolescents.

Of 780 patients treated for primary anterior shoulder dislocations, 33 (4.2%) were aged 12 to 17 years at the time of the dislocation. We clinically evaluated 28 of these patients a mean of 7.1 years after the initial dislocation. All patients were radiographed, and 15 underwent magnetic resonance imaging or computed arthrotomography of the shoulder. The primary dislocation had been traumatic in 21 patients (75%) and atraumatic in 7 patients (25%). Recurrent dislocations had occurred in 24 cases (86%), the number of recurrences ranging from 1 to 30. In the group with traumatic primary dislocations, the rate of recurrences was 92% and the mean number of redislocations was 7 in the patients who had been 14 to 17 years of age at the time of the initial injury, whereas the corresponding figures were 33% and 0.3 in the patients who had been 13 years of age or less at the time of the initial injury. Imaging studies showed a Bankart lesion in 80% of cases; each of these patients had had a traumatic primary dislocation and was 14 to 17 years old at the time of injury. During the follow-up period, operative stabilizing procedures had been performed in 7 cases. At follow-up evaluations, all nonoperated patients showed clinical evidence of anterior or multidirectional instability of the involved shoulder; of the operated patients, each of those with traumatic primary dislocations reported no recurrences and had a satisfactory result, whereas both of the patients with atraumatic primary dislocations continued to have subluxation and/or dislocations of the operated shoulder. In the 14- to 17-year-old adolescents with traumatic primary dislocations in whom imaging studies show Bankart lesions, there is an indication for prophylactic stabilizing surgery at the time of the initial injury.

Adolescent↗
PubMed1999

The postoperative shoulder.

Because disability and pain may persist or recur after shoulder surgery, visualization of the postoperative shoulder before further treatment is of great interest. Postoperative status is reevaluated most frequently after rotator cuff repair, capsulorrhaphy in patients with chronic instability, and acromioplasty, where postoperative symptoms are clinically difficult to distinguish from rerupture or inadequate surgical results. Postoperative evaluation or follow-up after surgical treatment of tumors or surgical repair of shoulder injuries are other potential indications. Whereas surgical procedures for osseous components primarily will be evaluated by plain film radiographs, magnetic resonance imaging is a valuable tool for other sites of surgical treatment, such as soft-tissue components, with further potential indication for magnetic resonance arthrography. This article focuses on normal and abnormal postoperative findings in the shoulder, with emphasis of magnetic resonance imaging, and discusses specific findings based on magnetic resonance arthrography.

Acromion↗
PubMed1990

Anterior staple capsulorrhaphy for recurrent dislocation of the shoulder: a clinical and biomechanical study.

Thirty-three anterior staple capsulorrhaphies of the shoulder were reviewed at an average 49.7 months postoperatively (range 12 to 127 months); one postoperative dislocation occurred. The patients' quality of athletic participation improved with surgical therapy in 50%, remained the same in 38%, and was lowered in 12%. Average loss of external rotation was 11.4 degrees with the arm adducted and 13.9 degrees with the arm abducted 90 degrees. A positive apprehension sign persisted in 50%. Shoulder function was good or excellent in 84%. Mild pain was admitted by 55%, moderate pain by 6%, and severe pain by 3%. Staple malpositioning or loosening was identified in 12 shoulders; six of these patients had attributable clinical problems. Biomechanical studies in porcine bone were used to demonstrate that predrilling facilitates proper staple positioning without compromising staple fixation strength and, in a synthetic trabecular model, that a 5 degrees variance in the alignment of the staple holder during staple insertion weakens the fixation strength by 51% (P less than .001). The operation usually prevents recurrent dislocation, permits recovery of normal (or near normal) shoulder motion, and allows satisfactory return to competitive athletics. If staple malpositioning and loosening occur, they may cause clinical problems, including degenerative arthritis. Though most patients (92%) stated they would again have the operation, when practical, we recommend other methods of repair of capsule and labral detachment.

Adult↗
PubMed2005

Corticosteroid injections for painful shoulders.

The painful shoulder is a common clinical entity with a broad array of possible causes. A caregiver for an affected patient needs to determine the aetiology for the pain, often relying primarily on the history and physical examination and supplemented with laboratory testing and imaging when needed. However, initial treatment decisions are often made before ordering these tests in situations not involving trauma. Most conditions affecting the shoulder are treated with conservative measures such as rest, physical therapy and analgesics. When such measures fail, local corticosteroid injections can be a valuable tool to help achieve symptom relief for a wide range of the most common conditions affecting the shoulder joint. This review aims to help the clinician distinguish among the commonly encountered causes of shoulder pain and guide therapy when the use of local corticosteroid injections is considered.

Arthritis↗
PubMedDate not supplied

Injuries to the shoulder in the throwing athlete. Part one: Biomechanics/pathophysiology/classification of injury.

Over the last decade, significant advances have been made in the study and understanding of shoulder mechanics. Much of this may be attributed to the use of more sophisticated technology to improve our ability to assess the shoulder in real-time athletics. As a consequence of these advances, our understanding of the pathophysiology of injury has also increased. Our manual examination skills have improved and our noninvasive diagnostic techniques have advanced greatly. New insight into forces at play during actions as complex as the throwing motion has allowed us to develop better protocols for the prevention and treatment of the most common injuries. Additionally, paralleling improvements in the understanding of shoulder kinematics and the pathophysiology of injury, advances in surgical techniques, particularly arthroscopy, have aided in the diagnosis of and the development of less invasive surgical treatments for injuries that do not respond to nonoperative measures. Undoubtedly, an up-to-date understanding of the developments in shoulder biomechanics, pathophysiology of injury, diagnostic techniques, and surgical management is necessary for the clinician who wishes to continue to apply proper skills in the sports medicine setting.

Athletic Injuries↗
PubMedDate not supplied

Shoulder injuries in golf.

Although often perceived as a leisurely activity, golf can be a demanding sport, which can result in injury, usually from overuse and sometimes from poor technique. The shoulder is a commonly affected site, with the lead shoulder, or the left shoulder in the right-handed golfer, particularly vulnerable to injury. A thorough understanding of the biomechanics of the golf swing is helpful in diagnosing and managing these injuries. Common shoulder problems affecting golfers include subacromial impingement, acromioclavicular arthrosis, rotator cuff tear, glenohumeral instability, and glenohumeral arthrosis. Although the majority of patients with these disorders will respond to nonsurgical treatment, including rest and a structured program of physical therapy, further benefits can be obtained with subtle modifications of the golf swing. Those golfers who fail to respond to nonsurgical management can often return to competitive play with appropriate surgical treatment.

Athletic Injuries↗
PubMedDate not supplied

Bankart procedure augmented by coracoid transfer for contact athletes with traumatic anterior shoulder instability.

We investigated the clinical efficacy of the Bankart procedure augmented by coracoid transfer for traumatic anterior shoulder instability in athletes playing contact sports. Eighty-three athletes (85 joints) with traumatic anterior shoulder instability who underwent the combined procedure were studied. The mean patient age at surgery was 21 years, and the mean follow-up period was 5.8 years (range, 2 to 12). According to the Rowe scoring system, the clinical results were graded as excellent for 58 shoulders, good for 21, fair for 5, and poor for 1, with an average score of 91 points. The overall success rate was 93%. A complete return to contact sports was achieved by 73 of the 83 patients (88%). The average loss of external rotation was 15 degrees with the arm at the side and 7 degrees with the arm in 90 degrees of abduction. The complications were nonunions in two cases, screw breakage in one case, and axillary nerve injury in one. This procedure can achieve a good clinical outcome for contact athletes with traumatic anterior shoulder instability.

Adolescent↗
PubMed2005

Recurrent anterior shoulder dislocation caused by a midsubstance complete capsular tear.

BACKGROUND: A midsubstance complete capsular tear is one of the well-known causes of anterior glenohumeral instability. However, its prevalence and clinical picture have not been well elucidated. The purpose of this study was to examine the prevalence of isolated complete capsular tears and to assess the clinical features as well as the results of surgical treatment of recurrent anterior glenohumeral instability caused by such tears. METHODS: Three hundred and three shoulders underwent surgery to treat recurrent anterior glenohumeral instability at our institution during a five-year period. Twelve (4.0%) of these shoulders had an isolated complete capsular tear as the main pathological condition. Those twelve patients (nine male and three female) were the subjects of the present study. The average age at the time of the operation was twenty-five years. Patient age; the cause of the initial dislocation; the position of the arm at the initial dislocation; and the findings of the preoperative physical examination, of computed tomographic arthrography, and at surgery were assessed. Eleven patients underwent arthroscopic capsular repair, and one was treated with an open capsular repair. RESULTS: The twelve patients either did not have a Hill-Sachs lesion or had a chondral indentation-type of Hill-Sachs lesion. When assessed with arthrography, the Hill-Sachs lesions were small compared with those in shoulders with an isolated Bankart lesion and, interestingly, they were quite similar in size to those seen with humeral avulsion of the inferior glenohumeral ligament. The average Rowe score for the twelve patients improved from 30.4 points preoperatively to 90.4 points at an average of thirty-one months postoperatively. CONCLUSIONS: The prevalence of isolated complete capsular tears causing recurrent glenohumeral instability was 4.0% (twelve of 303). These tears were associated with either a small or no Hill-Sachs lesion. We believe that a complete capsular tear should be recognized as one of the essential lesions causing recurrent anterior shoulder dislocation. Arthroscopic examination and repair can provide effective treatment.

Adolescent↗
PubMed1993

Applied MRI anatomy of the shoulder.

Magnetic resonance imaging (MRI) of the shoulder is rapidly evolving as the choice diagnostic procedure for management of shoulder derangement, particularly for soft tissue injuries not well delineated by conventional radiography. With application of appropriate MRI protocol/sequences and familiarity with applied shoulder MRI anatomy, valuable diagnostic information may be derived that can greatly assist management/therapy of common problems, such as rotator cuff tears, impingement, and instability as well as less frequent causes of shoulder pain and dysfunction.

Humans↗
PubMed2003

The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review.

OBJECTIVES: To evaluate the evidence for the effectiveness and cost-effectiveness of the newer diagnostic imaging tests as an addition to clinical examination and patient history for the diagnosis of soft tissue shoulder disorders. DATA SOURCES: Literature was identified from several sources including general medical databases. REVIEW METHODS: Studies were identified that evaluated clinical examination, ultrasound, magnetic resonance imaging (MRI), or magnetic resonance arthrography (MRA) in patients suspected of having soft tissue shoulder disorders. Outcomes assessed were clinical impingement syndrome or rotator cuff tear (full, partial or any). Only cohort studies were included. The methodological quality of included test accuracy studies was assessed using a formal quality assessment tool for diagnostic studies and the extraction of study findings was conducted in duplicate using a pre-designed and piloted data extraction form to avoid any errors. For each test, sensitivity, specificity and positive and negative likelihood ratios with 95% confidence intervals were calculated for each study. Where possible pooled estimates of sensitivity, specificity and likelihood ratios were calculated using random effects methods. Potential sources of heterogeneity were investigated by conducting subgroup analyses. RESULTS: In the included studies, the prevalence of rotator cuff disorders was generally high, partial verification of patients was common and in many cases patients who were selected retrospectively because they had undergone the reference test. Sample sizes were generally very small. Reference tests were often inappropriate with many studies using arthrography alone, despite problems with its sensitivity. For clinical assessment, 10 cohort studies were found that examined either the accuracy of individual tests or clinical examination as a whole: individual tests were either good at ruling out rotator cuff tears when negative (high sensitivity) or at ruling in such disorders when positive (high specificity), but small sample sizes meant that there was no conclusive evidence. Ultrasound was investigated in 38 cohort studies and found to be most accurate when used for the detection of full-thickness tears; sensitivity was lower for detection of partial-thickness tears. For MRI, 29 cohort studies were included. For full-thickness tears, overall pooled sensitivities and specificities were fairly high and the studies were not statistically heterogeneous; however for the detection of partial-thickness rotator cuff tears, the pooled sensitivity estimate was much lower. The results from six MRA studies suggested that it may be very accurate for detection of full-thickness rotator cuff tears, although its performance for the detection of partial-thickness tears was less consistent. Direct evidence for the performance of one test compared with another is very limited. CONCLUSIONS: The results suggest that clinical examination by specialists can rule out the presence of a rotator cuff tear, and that either MRI or ultrasound could equally be used for detection of full-thickness rotator cuff tears, although ultrasound may be better at picking up partial tears. Ultrasound also may be more cost-effective in a specialist hospital setting for identification of full-thickness tears. Further research suggestions include the need for large, well-designed, prospective studies of the diagnosis of shoulder pain, in particular a follow-up study of patients with shoulder pain in primary care and a prospective cohort study of clinical examination, ultrasound and MRI, alone and/or in combination.

Arthrography↗
PubMedDate not supplied

Shoulder imaging abnormalities in individuals with paraplegia.

Shoulder pain and rotator cuff tears are highly prevalent in individuals with paraplegia (PP). The purpose of this study was to use magnetic resonance imaging (MRI), plain radiographs, questionnaires, and physical examination to gain insight into the prevalence of shoulder disorders in individuals with PP. A total of 28 individuals with PP was recruited (mean age=35; mean year from injury=11.5). Each subject completed a questionnaire designed to identify arm pain, had a standard physical examination focusing on the shoulder, and underwent imaging studies (radiographic and MRI). Nine of the thirty-two subjects (36 percent) experienced shoulder pain in the month prior to testing. The MRI studies documented only one rotator cuff tear. Five subjects showed osteolysis of the distal clavicle by plain radiographic study. In two subjects this was seen bilaterally. Although no relationship was seen between pain and imaging abnormalities, stepwise linear regressions found a statistically significant positive relationship between imaging abnormalities and body mass index (BMI) (radiographic: beta= 0.56, p<0.01; MRI: beta=0.52, p<0.01). This study found a low prevalence of rotator cuff tears and a high prevalence of distal clavicle osteolysis in a sample of relatively young individuals with PP. Although there was only one tear identified by MRI, a number of subclinical abnormalities were seen and found to correlate with BMI.

Adolescent↗
PubMed2002

Anterior shoulder instability: histomorphometric study of the subscapularis and deltoid muscles.

Recurrent traumatic anterior shoulder dislocation results in soft tissues lesions around the glenohumeral joint. The subscapularis muscle is a major active stabilizer of the shoulder and the hypothesis of the current study is that one would expect pathologic changes within its substance secondary to the trauma. A histomorphometric study of the subscapularis muscle was done of 52 patients operated on for recurrent traumatic anterior shoulder dislocation. At the time of surgery biopsy specimens were taken of the subscapularis muscle and the ipsilateral deltoid muscle as a comparison and to see if any changes were present. The results revealed interstitial fibrosis within the subscapularis muscle compatible with muscle scarring, and modifications in the ratio of fiber types as usually is seen with disuse atrophy. Both of these findings may alter strength and stability and therefore the function of the glenohumeral joint. The histologic findings were not compatible with a denervation pattern. After traumatic anterior shoulder dislocation rehabilitation of the subscapularis muscle is recommended.

Adolescent↗
PubMedDate not supplied

The shoulder in baseball pitching: biomechanics and related injuries-part 1.

The extreme range of motion at the shoulder, the high angular velocities and torques, and the repetitious nature of the pitching motion combine to make the shoulder vulnerable to injury during the baseball pitch. An understanding of the biomechanics that contribute to shoulder injuries during each phase of the pitching motion can facilitate the athlete's diagnosis, treatment, and rehabilitation. Common injuries that occur during the late cocking and acceleration phases of the pitch include anterior instability and impingement, bicipital tendinitis, and subacromial impingement. Nonoperative treatment consisting of an initial period of rest and NSAIDS, followed by physical therapy and a gradual return to activity, is usually successful. When this approach fails, surgical intervention, either arthroscopic or open, may be necessary. Physical therapy and rehabilitation are directed toward restoring the integrity and strength of the dynamic and static stabilizers of the shoulder joint, yet preserving the range of motion necessary for performance. Through rehabilitation, the dedicated athlete can often return to the pitching mound at his previous level of performance.

Acceleration↗
PubMed1992

MRI of the shoulder.

MR imaging of the shoulder has become an important imaging modality for that joint. Excellent soft tissue contrast and multiplanar acquisition provide optimal assessment of muscle, tendons, hyaline and fibrous cartilage, joint capsules, fat, bursae and bone marrow. The most common indications for shoulder MRI are suspected rotator cuff tear, shoulder instability, osteonecrosis, neoplasm and infection. In this article we describe MR technique, special anatomy of the shoulder, and diagnostic MR criteria of common pathologic conditions.

Humans↗
PubMed1992

Shoulder problems in the weekend athlete.

With more competitive and recreational athletic pursuits now being undertaken by an aging population, the painful shoulder is seen frequently in the weekend athlete. Episodic stresses to soft-tissue restraints and musculotendinous units around the shoulder lead to a variety of overused pathologic entities. The two most common shoulder problems in the weekend athlete are irritation, swelling, and mechanical impingement; and tearing of the rotator cuff with traumatic shoulder instability (typically of an anterior direction).

Arthroscopy↗
PubMed2005

Scapular muscle tests in subjects with shoulder pain and functional loss: reliability and construct validity.

BACKGROUND AND PURPOSE: Scapular muscle performance evaluated with a handheld dynamometer (HHD) has been investigated only in people without shoulder dysfunction for test-retest reliability of data obtained with a single scapular muscle test. The purpose of this study was to assess the reliability, error, and validity of data obtained with an HHD for 4 scapular muscle tests in subjects with shoulder pain and functional loss. SUBJECTS AND METHODS: Subjects (N=40) with shoulder pain and functional loss were tested by measuring the kilograms applied with an HHD during 3 trials for muscle tests for the lower trapezius, upper trapezius, middle trapezius, and serratus anterior muscles. Concurrently, surface electromyography (sEMG) data were collected for the 4 muscles. The same procedures were performed 24 to 72 hours after the initial testing by the same tester. Muscle tests were performed 3 times, and the results were averaged for data analysis. RESULTS: Intraclass correlation coefficients for intratester reliability of measurements of isometric force obtained using an HHD ranged from .89 to .96. The standard error of the measure (90% confidence interval [CI]) ranged from 1.3 to 2.7 kg; the minimal detectable change (90% CI) ranged from 1.8 to 3.6 kg. Construct validity assessment, done by comparing the amounts of isometric muscle activity (sEMG) for each muscle across the 4 muscle tests, revealed that the muscle activity of the upper trapezius and lower trapezius muscles was highest during their respective tests. Conversely, the isometric muscle activity of the middle trapezius and serratus anterior muscles was not highest during their respective tests. DISCUSSION AND CONCLUSION: In people with shoulder pain and functional loss, the intrarater reliability and error over 1 to 3 days were established using an HHD for measurement of isometric force for the assessment of scapular muscle performance. Error values can be used to make decisions regarding individual patients. Construct validity was established for the lower and upper trapezius muscle tests; therefore, these tests are advocated for use. However, construct validity was not demonstrated for the serratus anterior and middle trapezius muscle tests as performed in this study. Further investigation of these muscle tests is warranted.

Activities of Daily Living↗
PubMed1992

Treatment of instability of the shoulder with an exercise program.

One hundred and forty shoulders in 115 patients that had a diagnosis of traumatic or atraumatic recurrent anterior, posterior, or multidirectional subluxation were treated with a specific set of muscle-strengthening exercises. Only twelve (16 per cent) of the seventy-four shoulders (sixty-eight patients) that had traumatic subluxation had a good or excellent result from the exercises, compared with fifty-three (80 per cent) of the sixty-six shoulders that had atraumatic subluxation. For this reason, each patient who has instability of the shoulder should be thoroughly evaluated if a successful result from conservative treatment is to be expected. Every effort must be made to identify the etiology of the instability through careful history-taking, physical examination, and radiographic evaluation.

Adolescent↗
PubMed1991

[Acute instability of the shoulder in athletes. The role of magnetic resonance in therapy planning].

Magnetic resonance imaging (MRI) of the shoulder was performed to evaluate both the actual role of this technique in the study and staging of acute shoulder instability, and its potentials as diagnostic tool, with particular reference to treatment planning. Seventeen athletes with acute shoulder instability were examined. All MRI examinations, subsequent to plain radiographs, were performed within 48 hours from the traumatic event. After MRI examination, 14 patients underwent physiotherapy (2 cases were subsequently submitted to arthrotomy), and only 3 cases underwent surgical treatment in the acute phase (2 arthrotomies and 1 arthroscopy). These cases, submitted to MRI in the acute phase and subsequently to surgery, showed anterior glenoid labrum involvement with good evidence of associated skeletal lesions (Hill-Sachs lesions in 1); changes in the inferior glenohumeral ligament complex (2 cases) were also observed. In the other examined cases, MRI always provided accurate information on the glenoid labra and the anterior capsular mechanism. When the superior glenohumeral ligament was investigated (9 cases of 17), no alterations were observed. Acting as natural contrast, the presence of joint effusion allows good visualization, on T1-weighted sequences, of the structures involved by the traumatic events. Contrast resolution improvement could be obtained by employing gradient-echo T2 weighted sequences, which proved to be quite valuable for a correct depiction of the lesions involving the inferior glenohumeral ligament complex. In conclusion, MRI can be considered as a valuable diagnostic method for the early evaluation of the acute shoulder instability, since it provides information of the utmost importance for the subsequent therapeutical approach.

Adolescent↗