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PubMed1998

[Role of magnetic resonance in hemodialysis patients with amyloid shoulder arthropathy].

PURPOSE: Amyloid shoulder arthropathy is a frequent finding in long-term hemodialysis patients. Assessing the symptoms is fundamental in the approach to these patients but their long life expectancy means that the correct imaging quantification of scapulohumeral joint impairment is just as important. We investigated the role of MRI in amyloid shoulder arthropathy in long-term hemodialysis patients. MATERIAL AND METHODS: From January, 1995, to December, 1996, twelve long-term (mean: 13 years) hemodialysis patients with amyloid shoulder arthropathy were examined with MRI. All of them had undergone physical examination to detect the most involved scapulohumeral joint. MRI was carried out with a 1.0 T Magnetom Impact unit (Siemens, Germany) using T1-weighted Turbo SE sequences at high resolution on coronal and sagittal planes, respectively parallel and perpendicular to the supraspinatus tendon, and FLASH sequences on the axial plane. Six patients were then submitted to surgery. RESULTS: MRI had identified 3/12 rotator cuff tears (always involving the supraspinatus tendon and other tendons), 7/12 rotator cuff tears from supraspinatus tendon injury, and 1/12 thickening and structural dishomogeneity of the supraspinatus tendon. Finally, no structural changes were shown in 1/12 cases. In addition, most MR examinations (11/12) showed some inhomogeneous material characterized by intermediate-to-low signal intensity on T1-weighted sequences; such changes were found in subacromial and subdeltoid bursas in part of the articular capsule and were always associated with hypointense nodular images in all sequences. Surgery was carried out in 6 patients and confirmed both the structural changes of the rotator cuff and the presence of amorphous material which appeared to be amyloid deposits at subsequent histology. MRI proved to be a very reliable tool even in the study of skeletal structural changes, permitting both the identification of periarticular calcifications and the accurate analysis and quantification of subchondral erosions. CONCLUSIONS: MRI was a very reliable tool not only in the study of rotator cuff tears due to amyloid deposition but also in the analysis of bone changes. Thus MRI could play a growing role in treatment planning.

Adult↗
PubMedDate not supplied

Shoulder pain in wheelchair athletes. The role of muscle imbalance.

Shoulder rotator cuff impingement syndrome is a common and disabling problem for the wheelchair athlete. In this study we investigated the role of shoulder strength imbalance as a factor for the development of this syndrome. Nineteen paraplegic male athletes underwent clinical and isokinetic examination of both shoulders with peak torque values measured in abduction, adduction, and internal and external rotation. Twenty athletic, able-bodied men without shoulder problems were tested as controls. Ten (26%) of the paraplegic athletes had rotator cuff impingement syndrome. The results of the isokinetic testing demonstrated that 1) the paraplegics' shoulders were stronger than the controls in all directions (P < 0.05); 2) the strength ratio of abduction: adduction was higher for paraplegic athletes (P < 0.05); 3) paraplegics' shoulders with rotator cuff impingement syndrome were weaker in adduction and external and internal rotation than the paraplegic athletes without impingement syndrome (P < 0.05); and 4) paraplegics' shoulders with rotator cuff impingement syndrome had higher abduction:adduction and abduction:internal rotation strength ratios than the shoulders of paraplegics without impingement syndrome (P < 0.05). We concluded that shoulder muscle imbalance, with comparative weakness of the humeral head depressors (rotators and adductors), may be a factor in the development and perpetuation of rotator cuff impingement syndrome in wheelchair athletes.

Adult↗
PubMed2006

The reverse shoulder prosthesis: A review of imaging features and complications.

BACKGROUND: The reverse shoulder prosthesis is a prosthesis that has been in clinical use in Europe since 1985 and was approved for use in the United States in 2004. This unique prosthesis has a baseplate attached to the glenoid, which holds a spherical component, while the humeral component includes a polyethylene insert that is flat. This design is the "reverse" configuration of that seen with a conventional arthroplasty, in which the spherical component is part of the humeral component. The indications for the reverse prosthesis are: (1) painful arthritis associated with irreparable rotator cuff tears (cuff tear arthropathy), (2) failed hemiarthroplasty with irreparable rotator cuff tears, (3) pseudoparalysis due to massive, irreparable rotator cuff tears, (4) some reconstructions after tumor resection, and (5) some fractures of the shoulder not repairable or reconstructable with other techniques. This prosthesis can produce a significant reduction in pain and some improvement in function for most of the indications mentioned. However, the unique configuration and the challenge of its insertion can result in a high incidence of a wide variety of unusual complications. Some of these complications, such as dislocation of the components, are similar to conventional shoulder replacement. Other complications, such as notching of the scapula and acromial stress fractures, are unique to this prosthesis. CONCLUSION: The configuration of the reverse prosthesis, its normal radiographic appearance and potential complications associated with its use are reviewed.

Arthroplasty, Replacement↗
PubMed1997

Special considerations in the athletic throwing shoulder.

Overhead athletes are susceptible to a number of shoulder problems due to the repetitive nature and force needed to perform at a competitive level. Frequently, the rotator cuff becomes injured due to primary or secondary impingement. In young athletes, subtle instability is often the cause of rotator cuff tendinitis, but will frequently respond to a coordinated rehabilitation program. Older athletes are more likely to have rotator cuff injuries due to anatomic changes in the coracoacromial arch. This article outlines the mechanism of injury to the rotator cuff and our approach in dealing with shoulder problems in the overhead athlete.

Biomechanical Phenomena↗
PubMedDate not supplied

Biomechanical effects of supraspinatus repair on the glenohumeral joint.

We repaired full-thickness rotator cuff tears in human cadaveric shoulder specimens. The purpose of this study was to determine whether a repaired supraspinatus will result in a change in joint forces, contact pressures and area, and position of the humerus relative to the glenoid compared with the pathologic and simulated complete-tear specimens. Force couples exist in the coronal plane between the deltoid and the inferior portion of the rotator cuff and in the transverse plane between the anterior cuff (subscapularis) and posterior cuff (infraspinatus and teres minor). This has served as a model for shoulder and rotator cuff research. Our model differs from previous studies in that the pectoralis major and latissimus dorsi/teres major were included because they are important contributors to shoulder function. Muscle force simulation was performed through a clamp, cable, and pneumatic system for the tendons of the rotator cuff, pectoralis major, and teres major/latissimus dorsi. Each specimen was tested in its native state of a full-thickness supraspinatus tear in 10 degrees and 60 degrees of abduction with neutral humeral rotation. In each position there were 2 loading conditions: (1) all muscles loaded with 60 N and (2) deltoid loaded with 90 N and 60 N for all others (3:2 ratio between the deltoid and supraspinatus). Pathologic tear, repaired, and simulated complete-tear conditions were subjected to the same testing sequence. After repair, there was an increase in percent inferior force in the 10 degrees abduction, 60-N loaded condition ( P = .02). The increase in percent inferior force may represent greater concavity-compression and spacer effect, which are both important functions of the supraspinatus. Contact pressure decreased in both the pathologic and simulated complete-tear conditions at 10 degrees abduction with 90-N deltoid loading ( P = .01). A corresponding increase in area was observed at this position for the pathologic tear condition only ( P = .01). This could represent greater concavity-compression, indicating that strengthening may provide a biomechanical benefit.

Aged↗
PubMed1995

Abnormal findings on magnetic resonance images of asymptomatic shoulders.

Magnetic resonance images of the shoulders of ninety-six asymptomatic individuals were evaluated to determine the prevalence of findings consistent with a tear of the rotator cuff. The scans were reviewed independently by two diagnostic radiologists who are experienced in the interpretation of magnetic resonance images of the shoulder. The over-all prevalence of tears of the rotator cuff in all age-groups was 34 per cent (thirty-three). There were fourteen full-thickness tears (15 per cent) and nineteen partial-thickness tears (20 per cent). The frequency of full-thickness and partial-thickness tears increased significantly with age (p < 0.001 and 0.05, respectively). Twenty-five (54 per cent) of the forty-six individuals who were more than sixty years old had a tear of the rotator cuff: thirteen (28 per cent) had a full-thickness tear and twelve (26 per cent) had a partial-thickness tear. Of the twenty-five individuals who were forty to sixty years old, one (4 per cent) had a full-thickness tear and six (24 per cent) had a partial-thickness tear. Of the twenty-five individuals who were nineteen to thirty-nine years old, none had a full-thickness tear and one (4 per cent) had a partial-thickness tear. Magnetic resonance imaging identified a high prevalence of tears of the rotator cuff in asymptomatic individuals. These tears were increasingly frequent with advancing age and were compatible with normal, painless, functional activity. The results of the present study emphasize the potential hazards of the use of magnetic resonance imaging scans alone as a basis for the determination of operative intervention in the absence of associated clinical findings.

Adult↗
PubMed2006

US appearance of the rotator cable with histologic correlation: preliminary results.

PURPOSE: To characterize the ultrasonographic (US) appearance of the rotator cuff cable in asymptomatic shoulders and in cadaveric specimens, with histologic comparison for the latter. MATERIALS AND METHODS: The cadaveric portion of this study was approved by the institution's Anatomical Donations Department. Institutional review board approval and informed consent were obtained from asymptomatic volunteers and clinical patients for the HIPAA-compliant portion of the study. Four fresh cadaveric shoulder specimens (two male subjects, 40 and 50 years old) were dissected, assessed for the presence of the rotator cable, and imaged with 12-MHz US. Histologic slides (hematoxylin-eosin stain) from three resected rotator cuff tendons were inspected for fibers in the expected location and orientation of the rotator cuff cable. The shoulders in 17 asymptomatic volunteers (seven men, two women; age range, 27-66 years; mean, 41 years) and contralateral asymptomatic shoulders in 10 patients (six men, four women; age range, 24-78 years; mean, 49 years) were scanned and evaluated for the presence and appearance of the rotator cable. RESULTS: The rotator cable was identified at gross dissection. Histologic examination and US of the cadaveric shoulders demonstrated an articular-sided fibrillar structure perpendicular to the rotator cuff tendon (average thickness and width, 1.2 mm and 4.5 mm, respectively). US of asymptomatic shoulders depicted a similar fibrillar structure in three (11%) shoulders up to 1.1-1.5 cm medial to the greater tuberosity (average thickness and width, 1.2 mm and 4.5 mm respectively). CONCLUSION: The rotator cable can be depicted with US.

Adult↗
PubMed1998

Cystic changes of the humeral head on MR imaging. Relation to age and cuff-tears.

We obtained MR images of 140 painful shoulders in 134 patients to determine the relationship between cystic changes of the humeral head and integrity of the rotator cuff. Cystic changes were observed in 49 shoulders (35%) and the commonest site was in the bare bone area of the anatomical neck, and the second commonest site was at the attachment of the supraspinatus tendon. Cystic changes in the bare bone area were observed equally often in shoulders with or without rotator cuff tears (27% and 18%, respectively) and were more frequently observed in the elderly. Cystic changes at the attachment of the supraspinatus and subscapularis tendons were specific to rotator cuff tears: they were observed in 28% of rotator cuff tears, but in none of those with an intact cuff. We conclude that there are two distinct types of cystic changes: one at the attachment of the supraspinatus and subscapularis tendons, which is closely related to tears of these tendons, and the other in the bare bone area of the anatomical neck, which is related to aging.

Adolescent↗
PubMed1991

[Analysis of the scapulo-humeral rhythm for periarthritis scapulohumeralis].

To clarify the scapulo-humeral rhythm in twenty-five patients with periarthritis scapulo-humeralis, the movements of the scapula and the humerus during arm elevation were measured and analysed using a fluoroscope and a computer, and the rhythm of five patient with rotator cuff tear was compared with that of seven normal subjects. The ratio of scapular movement to humeral one in the patients with severe shoulder contracture due to periarthritis scapulohumeralis was greater than that of patients with mild contracture and that of normal subjects. In the patients with rotator cuff tear, wider range of scapular rotation was observed in the early phase of the motion. During the early phase of arm elevation, the humeral head moved to the upper direction by means of gliding in the patients with severely contracted shoulder and rotator cuff tear, and in the patients with mildly contracted shoulder the humeral head moved to the upper direction by means of ball rolling. In the normal subjects no such upward movement of the humeral head was observed. We believe that the restriction of the glenohumeral joint motion and dysfunction of the rotator cuff, which were caused by periarthritis scapulohumeralis, may break down the scapulohumeral rhythm.

Aged↗
PubMed2004

[Reconstruction of shoulder abduction and external rotation in obstetric brachial plexus palsy].

OBJECTIVES: We evaluated the results of the subscapularis and pectoralis major muscle releases and the transfer of the latissimus dorsi/teres major muscles to the rotator cuff in patients with internal rotation contractures due to obstetric brachial plexus palsy. METHODS: Seventy patients (44 boys, 26 girls; mean age 7.6 years; range 2 to 16 years) underwent transfer of the latissimus dorsi/teres major muscles to the rotator cuff. Spinal root involvement was at C5-C6 in 19 patients, at C5-C7 in 16 patients, and at C5-T1 in 35 patients. In 46 patients, the subscapularis muscle was released from the anterior surface of the scapula, and in 55 patients, the pectoralis major muscle was released by fractional tenotomy. The glenohumeral joint was evaluated by anteroposterior direct graphies and axial magnetic resonance scans. According to the Waters-Peljovich grading system, all the patients had type I or type II deformities. Pre- and postoperative range of motion values and Mallet scores were compared. The mean follow-up period was 37.9 months (range 24 to 64 months). RESULTS: The mean shoulder abduction increased to 132.6 degrees (range 90 degrees to 170 degrees; mean gain 60.3 degrees) and external rotation increased to 81.1 degrees (range 30 degrees to 100 degrees; mean gain 58.7 degrees). The mean postoperative Mallet scores for global abduction and external rotation were 3.9; hand-to-head, to-mouth, and to-back scores were 3.7, 3.4, and 2.5, respectively. No serious complications were seen during the follow-up period. CONCLUSION: The results of reconstruction techniques employed in our study show satisfactory increases in shoulder abduction and external rotation in patients with a minimal glenohumeral deformity.

Adolescent↗
PubMed2000

MR arthrography of the shoulder: comparison of low-field (0.2 T) vs high-field (1.5 T) imaging.

The objective of this study was to compare the image quality, sensitivity, specificity, and diagnostic accuracy of an open low-field MR system (0.2 T) with a standard high-field MR system (1.5 T) after arthrography of the shoulder. Thirty-eight patients either with suspected chronic instability (n = 12) or rotator cuff abnormalities (n = 26) were examined. Intra-articular injection of diluted Gd-DTPA was followed in randomized order either first by imaging on an open 0.2-T system or on a 1.5-T system. The image material was evaluated independently by two radiologists in a blinded fashion with respect to overall image quality and the detection of rotator cuff as well as capsular and labral abnormalities. Surgical correlation was available in 27 (71%) of 38 patients. For both systems, sensitivity and specificity for rotator cuff tears were 100% each, and for labrum pathologies, these values were 100 and 93%, respectively. The agreement for detection of labral pathologies between low-field and high-field examinations was good (kappa = 0.69, kappa = 0.61). For the detection of full-thickness tears of the rotator cuff, the agreement between the low-field and high-field MR examinations was very good and significant (kappa = 0.94, kappa = 1, p < 0.001). Overall image quality was rated good in 17 (45%) and fair in 21 (55%) of 38 cases on the 0.2-T MR system, and good in 32 (84%) and fair in 6 (16%) of 38 cases on the 1.5-T system. Motion artifacts were considered low in 24 (63%) and moderate in 14 (37%) of 38 cases for the 0.2-T system and low in 34 (89%) and moderate in 4 (11%) for 1.5-T system. Based on our results, low-field MR compares favorably to high-field MR in the detection of major abnormalities of the glenohumeral joint, at least when MR arthrography is used. Disadvantages are the duration of the examination and thus the risk of reduced image quality caused by motion artifacts.

Adult↗
PubMed1996

Shoulder arthroscopy. New concepts.

Shoulder arthroscopy has undergone dramatic advancements in the past few years. New biomechanical concepts, such as the functional rotator cuff tear, have led to new treatments, such as partial repair of massive rotator cuff tears. Techniques have evolved to repair rotator cuff tears and Bankart lesions arthroscopically. The shoulder with multidirectional instability will likely soon be treatable arthroscopically. Arthroscopic approaches to adhesive capsulitis have been applied successfully. The concepts of instability impingement overlap and internal impingement have allowed better understanding of dysfunction in the shoulders of throwing athletes.

Arthroscopy↗
PubMedDate not supplied

An evaluation of the shoulder relocation test.

The purpose of this study was to evaluate the sensitivity, specificity, negative and positive predictive values, and accuracy of the shoulder relocation test in 100 patients who underwent shoulder surgery. Based on operative data and examination under anesthesia, the diagnoses were grouped into six categories: anterior instability (without cuff disease), posterior instability, rotator cuff disease (without associated anterior instability), acromioclavicular disorder, osteoarthrosis, and instability of the biceps tendon. The test was performed on the day of surgery by placing the arm in a position of 90 degrees of humerothoracic abduction and 90 degrees of external rotation (90 degrees/90 degrees). Patient responses of pain and apprehension (considered separately) were assessed in this position both with and without application of an anterior force to the proximal humerus. The relocation test assessed diminution of pain and apprehension after application of a posteriorly directed force to the proximal humerus relative to the position of 90 degrees/90 degrees alone and to the position of an anterior force being applied to the proximal humerus. Overall, 63 patients reported pain with 90 degrees/90 degrees; 74 reported pain when an anterior force to the proximal humerus was applied: the anterior instability group alone had 46 and 63 reports of pain, respectively; the rotator cuff group alone had 82 and 88 reports of pain, respectively. The only positive responses for apprehension were in the anterior instability group, of which 63% had apprehension with 90 degrees/90 degrees alone and 74 had apprehension when an anterior humeral force was applied.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation Studies as Topic↗
PubMed1995

Diagnostic value of clinical tests for shoulder impingement syndrome.

Results of three clinical tests for detecting shoulder impingement syndrome (Neer's, Hawkins', and Yocum's tests) and four tests for determining the location of the rotator cuff lesion (Jobe's test [supraspinatus], Patte's test [infraspinatus], lift-off test [subscapularis], and palm-up test [long head of the biceps brachii]) were compared to intraoperatively observed anatomic lesions in 55 consecutive patients who had surgery for Neer's syndrome. For Jobe's and Patte's tests, both pain (denoting tendinitis) and functional impairment (denoting tendon rupture) were evaluated. All clinical tests were done by the same examiner and all surgical procedures (acromioplasty with or without rotator cuff repair) by the same surgeon. The location and extent of the lesions (size of the tear in the 34 patients with rotator cuff defects) were determined intraoperatively. The sensitivity, specificity, and positive and negative predictive values of each test were calculated. Sensitivity was satisfactory but specificity was poor, in particular for determining the location and type of rotator cuff lesions. The severity of functional impairment during Jobe's and Patte's maneuvers was not correlated with the size of the tear.

Adult↗
PubMed2005

[Shoulder function and scores in 180 asymptomatic individuals aged over 75 years].

PURPOSE OF THE STUDY: The purpose of this study was to define the normal shoulder in patients aged over 75 years and to look for correlations between general health, mental status and shoulder function. MATERIALS AND METHODS: Shoulder motion, rotator cuff strength and abnormal movements were evaluated in 180 subjects over 75 without surgical history involving the shoulder. Body mass index (BMI) was determined for each subject. The Simple Shoulder Test (SST) was performed and the Constant and Murley score was calculated for each shoulder. The Beck test was used to assess depression. When joint function was impaired, supplementary x-ray and ultrasound examinations were performed. RESULTS: Asymptomatic pathological features (rotator cuff tears, stiffness, degenerative joint disease) were identified in 56% of the shoulders. Only 44% of the shoulders were free of pathological features. 56.4% of rotator cuff tears were found in the dominant shoulder; 13.9% of subjects had bilateral degenerative joint disease; 23.3% had bilateral stiffness. There were many associated conditions: cardiovascular (33%), pulmonary (28%), gastrointestinal (25.6%), diabetes (12.2%), tumors (10.6%). 18.3% of the subjects were depressive and 14.4% were taking treatment for depression. Shoulder motion and strength were correlated with BMI and nutritional status. Thin subjects (BMI < 20) had more rotator cuff tears. Obese subjects (BMI > 29.9) had more degenerative joint disease and joint stiffness. Demand for treatment and examinations were greater among depressed subjects. DISCUSSION AND CONCLUSION: Shoulder function is compatible with normal lifestyle in subjects over 75, corresponding to their desires and expectations. Shoulder function is correlated with body mass index and mental status. We should carefully assess shoulders in elderly subjects because good shoulder function, even if impaired, is often compatible with moderate stiffness, mild osteoarthritis, and rotator cuff tears, with no particular need for surgery.

Age Factors↗
PubMed1989

Ultrasonography of the tendons of the shoulder.

The purpose of the present study was to compare ultrasonographic signs with macroscopic and histological findings in lesions of the rotator cuff and the biceps tendon. Twenty-six shoulder joints from 10 male and 3 female cadavers, ranging in age from 40 to 89 years (mean 65.9), were examined with a linear array real-time ultrasonographic scanner provided with a 7.5 MHz transducer. Arthrotomy and histological preparations were made after ultrasonography. Thinning and discontinuity of echogenic homogenicity of the tendons of the rotator cuff were the most reliable ultrasonographic signs of a total tear of the tendon, but focal hyper- and hypo-echogenic changes of the tendons of the rotator cuff were unreliable criteria. Partial tears of the rotator cuff were difficult to determine with static ultrasonograms. Ultrasonography readily revealed discontinuity of echogenic homogenicity of the biceps tendon as a sign of a rupture of the tendon, which was commonly associated with rotator cuff tears.

Adult↗
PubMed1996

[Diagnosis of shoulder impingement syndrome].

This article reviews the pathogenesis and clinical and imaging findings in shoulder impingement syndrome. Shoulder impingement is caused by compression of the supraspinatus tendon underneath the coracoacromial arch, mainly in forward flexion of the arm. Different stages of impingement syndrome are described. Stage I relates to edema and hemorrhage of the supraspinatus tendon. Stage II is characterized by bursal inflammation and fibrosis, as well as tendinopathy. In stage III there is a tear of the rotator cuff. Clinical signs may overlap. Moreover, calcifying tendinitis, fractures and pain originating from the cervical spine may mimic shoulder impingement syndrome. Imaging is important for the exact diagnosis. Standard radiographs are the basis of imaging in shoulder impingement syndrome. They may demonstrate subchondral sclerosis of the major tuberosity, subacromial spurs, and form anomalies of the acromion. They are also important in the differential diagnosis of shoulder impingement syndrome and demonstrate calcifying tendinitis, fractures and neoplasm. Ultrasonography has found acceptance as a screening tool and even as a final diagnostic method by many authors. However, there is a high interobserver variability in the demonstration of rotator cuff tears. Its usefulness has therefore been questioned. MR imaging is probably the method of choice in the evaluation of the rotator cuff and surrounding structures. Several investigations have demonstrated that differentiation of early findings, such as tendinopathy versus partial tears, may be difficult with MR imaging. However, reproducibility for fullthickness tears appears to be higher than for sonography. Moreover, specificity appears to be superior to sonography. MR arthrography is not universally accepted. However, it allows for more exact differentiation of discrete findings and may be indicated in preoperative planning. Standard arthrography and CT have a limited role in the current assessment of the rotator cuff.

Diagnosis, Differential↗
PubMedDate not supplied

Comparison of magnetic resonance imaging and arthroscopy in the evaluation of shoulder pathology.

Fifty-seven subjects with shoulder pain, the cause of which was not clear on clinical examination, underwent magnetic resonance imaging (MRI) and arthroscopy. With arthroscopy as the standard of reference, the accuracy of MRI for diagnosing shoulder disease was assessed. Pathologic conditions were organized into 3 groups: (1) labral tears, (2) rotator cuff disease, and (3) other pathologic conditions. At arthroscopic evaluation there were 15 labral tears, 24 rotator cuff tears, and 27 other abnormalities. MRI identified 11 of the labral injuries, with accuracy of 62%, sensitivity 73%, and specificity 58%. Rotator cuff tears were identified by MRI with accuracy of 68%, sensitivity 96%, and specificity 49%. When partial rotator cuff tears were differentiated from complete tears, only 16 of 24 injuries were identified by MRI. Nonrotator cuff, nonlabral disease was identified with accuracy of 75%, sensitivity 63%, and specificity 87%. In our center MRI does not appear to be an accurate effective tool for assessing shoulder pathologic conditions in patients in whom the clinical picture is not clear and therefore may not be of assistance in surgical planning for patients with these difficult conditions.

Adult↗