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PubMed2005

Subscapularis tendon tears.

Pathology of the subscapularis tendon is both infrequently identified and not commonly considered as a major source of shoulder pain and dysfunction. Subscapularis tendon pathology can present as isolated tears; partial-thickness tears; anterosuperior tears, also involving the supraspinatus tendon; complete rotator cuff avulsion; and rotator interval lesions, in which instability of the long head of the biceps tendon may dominate the clinical presentation. Although an accurate physical examination is paramount, modalities such as arthroscopy, magnetic resonance imaging, and ultrasound have advanced knowledge of the spectrum of abnormalities involving the subscapularis tendon. Nonsurgical management may be effective for most partial tears. Surgically, open repair is more frequent than use of arthroscopic techniques. Tears of the subscapularis tendon portend a different prognosis than do supraspinatus tendon tears, especially when the injury is acute and diagnosis is delayed.

Arthroscopy↗
PubMed2002

Biomechanical comparison of effects of supraspinatus tendon detachments, tendon defects, and muscle retractions.

BACKGROUND: Rotator cuff ruptures are frequently associated with loss of strength of the shoulder. However, the characteristics of the rotator cuff tear that are responsible for the loss of force generation and transmission have not yet been identified. The purpose of this study was to compare the effects of supraspinatus tendon detachments, tendon defects, and muscle retractions on in vitro force transmission by the rotator cuff to the humerus. METHODS: The rotator cuff tendons from ten cadaver shoulders were loaded proportionally to the respective cross-sectional areas of their muscles. A fiberglass rod was cemented into the medullary canal of the humerus and connected to a three-component load cell for the measurement of the forces transmitted by the rotator cuff to the humerus. This study was performed with the humerus in a hanging arm position and with various sizes of supraspinatus tendon detachments, tendon defects, and muscle retractions. RESULTS: Detachment or creation of a defect involving one-third or two-thirds of the supraspinatus tendon resulted in a minor reduction in the force transmitted by the rotator cuff (< or =5%), while detachment or creation of a defect involving the whole tendon resulted in a moderate reduction (11% and 17%, respectively). Simulated muscle retraction involving one-third, two-thirds, and the whole tendon resulted in losses of torque measuring 19%, 36%, and 58%, respectively. Side-to-side repair of the one-third and two-thirds defects nearly restored the force transmission capability, whereas a deficit remained after side-to-side repair following complete resection. CONCLUSIONS: Our results support the rotator cable concept and correspond to the clinical observation that patients with a small rupture of the rotator cuff may present without a loss of shoulder strength. Muscle retraction is potentially an important factor responsible for loss of shoulder strength following large rotator cuff ruptures. CLINICAL RELEVANCE: Supraspinatus muscle retraction diminishes glenohumeral abduction torque significantly more than either a defect in the tendon or a simple detachment of the tendon from the tuberosity. In cases of irreparable defects, side-to-side repair may be worthwhile to restore muscle tension and the integrity of the rotator cable.

Biomechanical Phenomena↗
PubMed2005

Simplified arthroscopic rotator interval capsule closure: an alternative technique.

The anatomy of the "coracoid eclipse" of the rotator cuff, the rotator interval, has been studied extensively. Its importance in shoulder stability with respect to inferior and posterior translation has been described. Historically, open repairs for instability indirectly addressed interval lesions and closure based simply on the definition of the deltopectoral approach with its subscapularis advancement and capsular shift in a "pants-over-vest" manner. With results of arthroscopic repairs of glenohumeral instability approaching those of open procedures, the importance of simplification without sacrificing outcome has become a forefront in arthroscopic shoulder surgery. We present an alternative technique for interval closure by means of a 3/32-inch smooth Steinmann pin modified at its proximal and distal ends. A standard 3-portal technique consisting of the anterior superior portal, anterior mid-glenoid portal, and the posterior superior portal is used. The technique does not require the use of a suture shuttle nor does it require the placement of the arthroscope in the subacromial space for suture tying. A Tennessee slider knot is tied intra-articularly, thus allowing for tension modification before definitive alternate locking half-hitch placement. Intra-articular knot tying also allows for added security because suture slack is eliminated, thus avoiding air knots.

Arthroscopy↗
PubMed2003

Corticosteroid injections for shoulder pain.

BACKGROUND: While many treatments, including corticosteroid injections in and around the shoulder, are advocated to be of benefit for shoulder pain, few are of proven efficacy. This review of corticosteroid injections for shoulder pain is one in a series of reviews of varying interventions for shoulder disorders. OBJECTIVES: To determine the efficacy and safety of corticosteroid injections in the treatment of adults with shoulder pain. SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL, Central and Science Citation Index were searched up to and including June 2002. SELECTION CRITERIA: Randomised and pseudo-randomised trials in all languages of corticosteroid injections compared to placebo or another intervention, or of varying types and dosages of steroid injection in adults with shoulder pain. Specific exclusions were duration of shoulder pain less than three weeks, rheumatoid arthritis, polymyalgia rheumatica and fracture. DATA COLLECTION AND ANALYSIS: Trial inclusion and methodological quality was assessed by two independent reviewers according to predetermined criteria. Results are presented separately for rotator cuff disease, adhesive capsulitis, full thickness rotator cuff tear and mixed diagnoses, and, where possible, combined in meta-analysis. MAIN RESULTS: Twenty-six trials met inclusion criteria. The number, site and dosage of injections varied widely between studies. The number of participants per trial ranged from 20 to 114 (median 52 participants). Methodological quality was variable. For rotator cuff disease, subacromial steroid injection was demonstrated to have a small benefit over placebo in some trials however no benefit of subacromial steroid injection over NSAID was demonstrated based upon the pooled results of three trials. For adhesive capsulitis, two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling of any of the trials. One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term (success at seven weeks RR=1.66 (1.21, 2.28). REVIEWER'S CONCLUSIONS: Despite many RCTs of corticosteroid injections for shoulder pain, their small sample sizes, variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment. Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained. There is a need for further trials investigating the efficacy of corticosteroid injections for shoulder pain. Other important issues that remain to be clarified include whether the accuracy of needle placement, anatomical site, frequency, dose and type of corticosteroid influences efficacy.

Adrenal Cortex Hormones↗
PubMed1993

Magnetic resonance arthrography of the shoulder. A new technique of shoulder imaging.

Although magnetic resonance imaging is very sensitive and even though pathology in the rotator cuff is readily detected, it is often difficult to distinguish between complete rotator cuff tears, partial rotator cuff tears, and area of tendinitis. This article reports the results of a new technique for evaluation of shoulder pathology, which the authors have labeled magnetic resonance arthrography, and compares the results of magnetic resonance arthrography with those of conventional magnetic resonance imaging.

Adolescent↗
PubMed2001

Improvement in comfort and function after cuff repair without acromioplasty.

The repair of full thickness rotator cuff tears traditionally has included acromioplasty and coracoacromial ligament section. Acromioplasty can be complicated by deltoid detachment, compromise of the deltoid lever arm, anterosuperior instability, and adhesions of the rotator cuff tendons under the bleeding cancellous bone of the osteotomized acromion. This report concerns the improvement in shoulder function at a minimum of 2 years after 27 full thickness rotator cuff repairs were done without deltoid detachment, acromioplasty, or section of the coracoacromial ligament. The mean number of Simple Shoulder Test functions that the patients could do increased from six of 12 before surgery to 10 of 12 at an average followup of 4 years after surgery. Eight of 12 individual Simple Shoulder Test functions were significantly improved after the procedure. There also was a significant improvement in the Short Form-36 comfort, physical role function, and mental health scores. When done without acromioplasty, cuff repair avoids the possibility of deltoid detachment, altered deltoid mechanics, anterosuperior instability, and tendon scarring to the cancellous undersurface of the acromion.

Female↗
PubMed2002

Anterior internal impingement: An arthroscopic observation.

PURPOSE: The source of pain in patients with a stable shoulder and clinical signs of impingement is traditionally thought to be subacromial or outlet impingement, as popularized by Neer. This report introduces the concept of anterior internal impingement in patients with signs and symptoms of classic impingement syndrome and arthroscopic evidence of articular-side partial rotator cuff tear. Contact that occurs between the fragmented undersurface of the rotator cuff and the anterosuperior labrum is the apparent source of pain in these patients. TYPE OF STUDY: Case series. METHODS: Ten patients with a primary symptom of pain and an arthroscopic finding of a partial rotator cuff tear were reviewed. Arthroscopic visualization of the subacromial space revealed no evidence of subacromial impingement or bursitis in any patient. All patients had clinical signs and symptoms of classic impingement. The initial part of the surgical procedure consisted of a complete diagnostic arthroscopy in a low-volume gas medium using a single posterior portal. While performing the Hawkins test, the locations of any areas of abnormal soft-tissue contact and impingement were observed directly. RESULTS: There was anterior internal impingement in all 10 patients with partial-thickness rotator cuff tears. The abnormal and fragmented rotator cuff tissue made contact with the anterior superior labrum when the shoulder was visualized from the posterior portal while performing the Hawkins test. Preoperative magnetic resonance imaging correctly showed a partial-thickness rotator cuff tear in 20% of the cases. CONCLUSIONS: Recognition of anterior internal impingement as a clinical entity is important because magnetic resonance imaging results are often misleading. This is of particular importance in young patients with isolated lesions in whom arthroscopic acromioplasty and capsular reefing procedures would be unnecessary. When anterior internal impingement is recognized as the source of unresolved shoulder pain, patient selection for surgery and procedure selection can be improved.

Adult↗
PubMed2005

Inhomogeneous mechanical behavior of the human supraspinatus tendon under uniaxial loading.

Disorders of the rotator cuff, particularly tears of the rotator cuff tendons, cause significant shoulder disability. Among numerous factors thought to be responsible for the initiation and progression of supraspinatus tears are those related to the tendon's biomechanical properties. We hypothesized that in supraspinatus tendons subjected to tensile loading a strain gradient (difference) exists between the articular and bursal tendon surfaces, that regional strain differences exist on each of these two tendon surfaces, and that tendon surface strains vary with glenohumeral abduction. To test these hypotheses, the intrinsic inhomogeneous deformational characteristics of the articular and bursal surfaces of eight intact human cadaveric supraspinatus tendons were studied at three glenohumeral abduction angles using a novel multiple strain measuring system which simultaneously recorded surface marker displacements on two opposing soft tissue surfaces. Under applied tensile loads, the articular surface exhibited greater strain at 22 degrees (7.4+/-2.6% vs. 1.3+/-0.7%, p=0.0002) and 63 degrees (6.4+/-1.6% vs. 2.7+/-1.2%, p=0.0001) whereas the bursal surface exhibited greater strain at 90 degrees (7.6+/-2.8% vs. 4.9+/-0.4%, p=0.013). At all abduction angles, insertion strains were higher than those of the mid-tendon and tendon-muscle junction regions. The existence of inhomogeneous surface strains in the intact supraspinatus tendon demonstrates that intratendinous shear occurs within the tendon. The higher strain on the articular side of the tendon, especially at the insertion region, suggests a propensity for tears to initiate in the articular tendinous zone.

Adult↗
PubMed1988

Peribursal fat plane of the shoulder: anatomic study and clinical experience.

A comprehensive anatomic and radiographic analysis of the peribursal fat plane in 12 cadavers confirmed that the fat plane seen on radiographs represents extrasynovial fat lining the subacromial bursa and documented the anatomic relations of the bursa. A three-part retrospective clinical evaluation of rotator cuff tears, calcific tendinitis, and rheumatoid arthritis was performed. Two osteoradiologists blindly graded the appearance of the peribursal fat plane with the shoulder in external versus internal rotation in 21 patients with arthrographically intact rotator cuffs and 21 patients with disrupted rotator cuffs. The peribursal fat plane was seen better with disrupted rotator cuffs. The peribursal fat plane was seen better with the shoulder in internal rotation and was seen in 60% of control subjects but only 21% of patients with rotator cuff tears. Partial or complete obliteration of this fat plane is a sensitive (79%) but less specific (60%) indicator of rotator cuff tears. Obliteration of the peribursal fat plane by inflammatory processes in adjacent tissues, including calcific tendinitis and rheumatoid arthritis, occurred with a high frequency.

Adipose Tissue↗
PubMedDate not supplied

Biomechanics of the shoulder.

Man's shoulder girdle is of the general pattern of his tree-swinging ancestors. With assumption of the upright posture, man's thorax has flattened from anterior-posterior. This results in a rotation of the scapula to a position of 45 degrees with the sagittal plane. In addition to this, man's forearm is habitually used in a position of approximately 45 degrees of internal rotation. This places the biceps tendon "off its trolley" and leads to biceps tinosynovitis. Motions of the glenohumeral joints result from the force couple of the deltoid muscle plus the rotator cuff muscles. The rotator cuff alone can abduct the arm with 50% force throughout the full range of its motion. In the absence of the supraspinatus muscle, however, the force couple is disrupted. Although initiation of abduction is with full force, the force rapidly falls off to 90 degrees. Above 90 degrees the arm can barely support its own weight. Although the shoulder undergoes progressive degenerative changes with age, the necessity for a joint implant, either partial or total--although successful--is rare.

Animals↗
PubMed2005

Effect of cyclic loading on new polyblend suture coupled with different anchors.

BACKGROUND: Secure tendon-to-bone fixation is essential for successful rotator cuff repair. Biomechanical properties of devices used in rotator cuff repair should be better understood. PURPOSE: To evaluate the response to incremental cyclic loading of 6 different anchor-suture complexes commonly used in rotator cuff repair. STUDY DESIGN: Controlled laboratory study. METHODS: Two absorbable anchors 5 mm and 6.5 mm in diameter and 1 metallic anchor, coupled with Ethibond or FiberWire, were tested on 5 pairs of fresh-frozen human cadaveric shoulders. An incremental cyclic load was applied until failure using a Zwich-Roell Z010 electromechanical testing machine. The ultimate failure load and mode of failure were recorded. An analysis of variance model was used for statistical analysis. RESULTS: The FiberWire suture coupled with both absorbable and metallic anchors provided statistically significantly stronger fixation. However, although the metallic anchors in most cases failed because of slippage of the anchor, absorbable anchors failed because of rupture of the eyelet. CONCLUSIONS: The FiberWire seems to increase the strength of fixation devices under cyclic load using both absorbable and metallic anchors, with relevant differences in failure mode (slippage of the metallic anchor and eyelet failure in the absorbable anchor). CLINICAL RELEVANCE: Use of the FiberWire suture might change the mode of failure of the suture-anchor complexes.

Aged↗
PubMed2000

Direct MR arthrography of the shoulder: is exercise prior to imaging beneficial or detrimental?

PURPOSE: To define the beneficial and detrimental effects of adding exercise to direct magnetic resonance (MR) shoulder arthrography. MATERIALS AND METHODS: Direct, intraarticular, gadolinium arthrography of the shoulder was performed in 41 patients, who underwent 1.5-T MR imaging before and after 1 minute of arm swinging. Fourteen milliliters of dilute gadolinium solution was injected. Two readers blinded to exercise independently graded the randomly distributed images with a five-point scale for capsular contrast material resorption; extraarticular contrast material leakage; rotator cuff, glenoid labrum, and anterior capsule conspicuity; and partial-thickness or full-thickness rotator cuff tear and labral tear detectability. The sign test was performed to evaluate the significance of differences between preexercise and postexercise grading for each reader. A second review was performed, with direct side-by-side comparison of preexercise and postexercise images. RESULTS: There was evidence of increased capsular resorption after exercise but no alteration in the depiction of the rotator cuff tendons or glenoid labrum. There was no significant extraarticular contrast material leakage after exercise and no alteration in depiction of the anterior capsule. There was no difference in the detectability of rotator cuff or labral tears. CONCLUSION: Exercise with direct shoulder MR arthrography has no beneficial or detrimental effect on image quality or on the depiction of rotator cuff or labral tears.

Adolescent↗
PubMed2006

[Non-traumatic pathology of the shoulder: medical treatment].

Recently published meta-analyses emphasized weak methodology of clinical research evaluating medical treatment of non-traumatic shoulder pathology. Experts recommend medical treatment as the first step in the management of rotator cuff tendinopathies, the focus of this review. This step precedes surgical treatment of rotator cuff tear with the objective of recovering passive motion of the shoulder. It can be the unique therapeutic phase of rotator cuff tear or simple tendinopathy when clinical results match functional needs of the patient. Therefore, the physician prior treatment has to establish a lesion diagnostic, which is necessary to propose an appropriate strategy. Medical treatment includes NSAID, local injections of corticosteroids and physiotherapy with the double objective of a painless shoulder and normal range of motion. In case rotator cuff calcifying tendinitis, medical treatment is specific with first NSAID and local injections of cortico-steroïds, second needle aspiration and third arthroscopic removal, which remains the gold-standard procedure when other treatments failed.

Adrenal Cortex Hormones↗
PubMed1989

[Etiology of sub-acromial impingement syndrome--a biomechanical study].

Eight fresh shoulder specimen were dissected and the functional relationship of the rotator cuff tendons to the acromion was demonstrated through various arcs of shoulder motion. The scapula was fixed and the arm was elevated, rotated, and abducted by pulling the muscle tendon according to EMG activities. Using FUJI compression films the subacromial compression of the rotator cuff was measured. Different forms of acromion were tested. While moving the shoulder with normal relationship of deltoid to rotator cuff, there is no -or at least less than 0.1 mPa compression of the rotator cuff in the subacromial space. Weakness of the rotator cuff results in a moderate compression of 0.6 mPa. In type III acromion there was significant increase up to 1.0 mPa between the acromion and the rotator cuff. This study suggests, that a mechanical subacromial compression only occurs in shoulder joints with a Bigliani acromion type III and/or in joints with a imbalance of the deltoid/rotator cuff relation. Thus an acromioplasty should be primarily undertaken only if the pathology affects the acromion. If there is a muscle imbalance, we recommend a special rehabilitation program in order to strengthen the cuff-muscles the first place.

Acromion↗
PubMed2002

Intratendinous strain fields of the intact supraspinatus tendon: the effect of glenohumeral joint position and tendon region.

Rotator cuff tears are a common shoulder pathology and are hypothesized to relate to excessive tissue deformation. Few data exist, however, describing deformation of the rotator cuff as an intact, functional unit. Our purpose was to determine regional variations of intratendinous rotator cuff strain over a range of clinically relevant joint positions. A novel, MRI-based technique was utilized to quantify intratendinous strains in cadaveric shoulder specimens at 15 degrees, 30 degrees, 45 degrees, and 60 degrees of glenohumeral abduction in the scapular plane. The strain data were grouped into superior, middle, and inferior locations across the region where most rotator cuff tears occur clinically. A repeated measures ANOVA assessed the effects of joint position and tendon region on intratendinous strain. Few differences in intratendinous strain existed across tendon regions, but joint position had a pronounced effect. Specifically, intratendinous strain increased with increasing joint angle, and the 60 degrees strain was significantly greater than the 15 degrees strain across all tendon regions. These data suggest that joint position plays a larger role in rotator cuff mechanics than previously believed. Future studies will utilize this technique for quantifying intratendinous strain to assess the effects of partial-thickness rotator cuff tears.

Adult↗
PubMed2004

Internal impingement of the shoulder in flexion.

Contact of the rotator cuff to the superior glenoid with the arm in flexion has been described and postulated to be a source of rotator cuff disease. The goals of the current study were to document the existence of internal impingement in flexion arthroscopically and to determine its prevalence in patients with various diseases. Also, we attempted to determine the clinical significance of internal impingement in flexion by investigating the associations between internal impingement in flexion and the preoperative and intraoperative findings. A consecutive case series of 376 patients having arthroscopy of the shoulder were entered prospectively into this study. During arthroscopy, intraarticular lesions were evaluated and the presence of contact of the rotator cuff to the superior glenoid and the degree of flexion making the contact were noted. Statistical analysis was done with two dependent variables defined: the presence of internal impingement in flexion and the flexion degree making internal impingement in flexion. Of the 376 patients, 277 (74%) had internal impingement in flexion and 99 (26%) did not have internal impingement in flexion. There were no statistically significant differences in the prevalence of internal impingement in flexion according to the primary diagnoses. Statistical analysis revealed that the presence of internal impingement in flexion was associated with Type II superior labrum anterior posterior (SLAP) lesions and the presence of internal impingement of the rotator cuff to the superior glenoid in abduction and external rotation. There was a significant relationship between rotator cuff disease and decreasing angle of contact for internal impingement in flexion. This study showed that internal impingement in flexion is common in a cohort of patients having shoulder surgery, with an overall prevalence of 74%, and that internal impingement in flexion may contribute to the development of Type II SLAP lesions and rotator cuff disease.

Adolescent↗
PubMed2004

Material reaction to suture anchor.

The authors present a case of material reaction to suture anchor, which is rarely reported. Leukocyte rate, leukocyte differential, multiple cultures, and gram stain test could not prove infection. A second surgery for exploration of the shoulder joint was performed to reconstruct the rotator cuff without using anchors, and the rotator cuff tear healed after the second surgery. During the second surgery, the bone surrounding the anchors was found to be eroded and substituted with necrotic tissue. The anchors protruded outside the bone. The pathological examination of the necrotic tissue showed multinucleated giant cells of foreign body type, some of which had engulfed minute splinters of particulate foreign material. Either metal- or suture-induced bioreaction is suspected in this case.

Aged↗
PubMed2003

Milwaukee shoulder: correlating possible etiologic variables.

The current study evaluated the relative correlation of apatite crystal-induced inflammation and rotator cuff deficiency in the development of cuff tear arthropathy. Thirty-seven patients with full thickness rotator cuff tears were evaluated by history, physical examination, and plain radiographs. Thirty patients had surgical intervention for their rotator cuff defects, and calipers were used intraoperatively to quantify the size of the tear in its largest diameter. The remaining seven patients were treated nonoperatively and the size of the tear was quantified using magnetic resonance imaging. Synovial fluid was obtained from all patients and analyzed for crystal content using an alizarin red stain. Synovial fluid also was analyzed for leukocyte count and differential, prostaglandin E, and matrix metalloproteinase. An unpaired Student's t test revealed that significantly higher levels of prostaglandin E were found in the synovial fluid of patients with apatite crystals, shown by alizarin red stain. Chi squared analysis showed that patients with elevated crystal levels were significantly more likely to have large rotator cuff tears or glenohumeral arthritis. Establishing such relations potentially can elucidate the etiology and treatment of this complex disorder.(2) (2)

Arthritis↗