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PubMedDate not supplied

Comparison of open and arthroscopic stabilization for recurrent shoulder dislocation in patients with a Bankart lesion.

We performed a prospective study of 117 patients (119 shoulders) with symptomatic, recurrent anterior posttraumatic shoulder instability to compare open versus arthroscopic reconstruction. Arthroscopic reconstructions (N = 66) were performed using bioabsorbable tacks (Suretac fixators), whereas open reconstructions (N = 53) were performed with suture anchors. All of the patients had a Bankart lesion. Independent observers examined 108 of the 119 shoulders (91%) at a median follow-up period of 28 months (range, 24 to 63) for the arthroscopic group and 36 months (range, 24 to 63) for the open group. The recurrence rate, including both dislocations and subluxations, was 9 of 60 (15%) in the arthroscopic group, compared with 5 of 48 (10%) in the open group. At follow-up, the Rowe score was 93 points (range, 39 to 100) and the Constant score was 91 points (range, 56 to 100) in the arthroscopic group, compared with 89 points (range, 53 to 100 and 57 to 100 for the Rowe and Constant scores, respectively) for both scores in the open group. The only significant difference was in external rotation in abduction, which was 90 degrees (range, 50 degrees to 135 degrees) in the arthroscopic group and 80 degrees (range, 25 degrees to 115 degrees) in the open group. Both methods produced stable and well-functioning shoulders in the majority of patients.

Adolescent↗
PubMedDate not supplied

Relevance of arm position and muscle activity on three-dimensional glenohumeral translation in patients with traumatic and atraumatic shoulder instability.

BACKGROUND: No quantitative data on glenohumeral translation exist allowing one to distinguish insufficiency of the active or passive stabilizers in different forms of shoulder instability. HYPOTHESIS: To determine whether 1) in traumatic or atraumatic shoulder instability an increase of glenohumeral translation can be observed in specific relevant arm positions, 2) muscle activity leads to recentering of the humeral head, and 3) there exist differences between traumatic and atraumatic instability. STUDY DESIGN: Prospective clinical trial. METHODS: In 12 patients with traumatic and 10 patients with atraumatic instability, both shoulders were examined in different arm positions-with and without muscle activity-by using open magnetic resonance imaging and a three-dimensional postprocessing technique. RESULTS: At 90 degrees of abduction and external rotation, translation (anterior-inferior) was significantly higher in patients with traumatic unstable shoulders compared with their contralateral side (3.6 +/- 1.5 versus 0.7 +/- 1.6 mm). In patients with atraumatic instability, significantly increased translation (4.7 +/- 2.0 mm) was observed, with the direction being nonuniform. Muscle activity led to significant recentering in traumatic but not in atraumatic instability. CONCLUSIONS: In traumatic instability, increased translation was observed only in functionally important arm positions, whereas intact active stabilizers demonstrate sufficient recentering. In atraumatic instability, a decentralized head position was recorded also during muscle activity, suggesting alterations of the active stabilizers. CLINICAL RELEVANCE: These data are relevant for optimizing diagnostics and therapeutic strategies.

Adolescent↗
PubMed2005

Biomechanics of the shoulder in youth baseball pitchers: implications for the development of proximal humeral epiphysiolysis and humeral retrotorsion.

BACKGROUND: The effects of repetitive throwing on the shoulders of developing athletes are not well understood because of the paucity of data describing the biomechanics of youth pitchers and the plasticity of the developing skeleton. HYPOTHESIS: The direction and magnitude of the stresses that exist at the proximal humeral physis during the fastball pitching motion are consistent with the development of proximal humeral epiphysiolysis (Little League shoulder) and/or humeral retro-torsion. STUDY DESIGN: Descriptive laboratory study. METHODS: A total of 14 elite youth baseball pitchers (mean age, 12.1 +/- 0.4 years) were filmed from the front and dominant side while throwing fastballs in a simulated game. The net force and torque acting on the humerus throughout the throwing motion were calculated using standard biomechanical techniques. RESULTS: The external rotation torque about the long axis of the humerus reached a peak value of 17.7 +/- 3.5 N.m (2.7% +/- 0.3% body weight x height) just before maximum shoulder external rotation. A shoulder distraction force of 214.7 +/- 47.2 N (49.8% +/- 8.3% body weight) occurred at, or just after, ball release. CONCLUSION: Shear stress arising from the high torque late in the arm-cocking phase is large enough to lead to deformation of the weak proximal humeral epiphyseal cartilage, causing either humeral retrotorsion or proximal humeral epiphysiolysis over time. The stresses generated by the external rotation torque are much greater than those caused by distraction forces generated during the pitching motion of youth baseball pitchers. CLINICAL RELEVANCE: The motion of throwing fastballs by youth baseball pitchers results in force components consistent with proposed mechanisms for 2 clinical entities.

Baseball↗
PubMedDate not supplied

Torque production in the shoulder of the normal young adult male. The interaction of function, dominance, joint angle, and angular velocity.

Shoulder torque measurements were obtained from 36 normal young adult males during flexion, abduction, internal rotation, and external rotation. Normative, angle-specific torque measurements were determined under isometric conditions and isokinetically at 48 deg/sec. The effects of dominance, angular velocity, and joint position were determined and a method provided for determining the expected maximal torque at a specific speed and position based upon torque measurements from the contralateral shoulder. This method can be used in cases of unilateral shoulder abnormalities to predict normative torque values for the affected side based on torque measurements from the unaffected shoulder.

Adult↗
PubMedDate not supplied

The painful shoulder during freestyle swimming. An electromyographic cinematographic analysis of twelve muscles.

The purpose of this paper is to describe the patterns of activity of 12 shoulder muscles in painful shoulders, and compare those patterns of activity with normal shoulders. The results show significant differences in 7 of the 12 muscles. Those muscles included the anterior deltoid, middle deltoid, infraspinatus, subscapularis, upper trapezius, rhomboids, and the serratus anterior. There were no significant differences between muscle activity patterns of normal versus painful shoulders in the latissimus dorsi, pectoralis major, teres minor, supraspinatus, or the posterior deltoid. This information will contribute to the development of muscle conditioning programs to optimize performance and prevent injury, as well as develop programs for scientific rehabilitation strengthening.

Adult↗
PubMedDate not supplied

Arthroscopic suture repair of superior labral detachment lesions of the shoulder.

Twenty consecutive patients with superior labral anterior and posterior lesions of the shoulder involving the biceps attachment to the labrum (Snyder types II and IV) were repaired arthroscopically and reviewed post-operatively to evaluate the efficacy of the technique in the management of this recently described injury pattern. Follow-up time averaged 21 months (range, 12 to 42). All patients were managed by an arthroscopic repair technique that included debridement of the frayed labrum and abrasion of the superior glenoid neck, followed by the placement of multiple sutures into the torn labrum-biceps tendon complex using a Caspari suture punch. Patients were reexamined, and the results were quantitated with the shoulder evaluation form of the American Shoulder and Elbow Surgeons and with the Rowe rating scale. On evaluation, all patients obtained good or excellent results. This suture technique is recommended in the management of unstable superior labral detachment lesions of the shoulder.

Adolescent↗
PubMedDate not supplied

Magnetic resonance imaging of the glenoid labrum in anterior shoulder instability.

Detachment of the anterior inferior labrum and inferior glenohumeral ligament complex from the glenoid is a common lesion encountered in anterior shoulder instability while other types of labral lesions are associated with symptoms that mimic instability. Accurate delineation of labral lesion is, therefore, key in managing shoulder problems. In a prospective double-blinded fashion, we compared the magnetic resonance imaging findings with those noted at surgery in 33 patients with possible anterior shoulder instability. Of 28 surgically confirmed labral lesions, 21 were detected by imaging. Sensitivity was 75%, specificity 100%, while positive and negative predictive values were 100% and 41%, respectively. Overall accuracy was 79%. Based on a literature review and our clinical experience, we developed a classification of glenoid labra according to the type and severity of the lesions. Method of treatment correlated with clinical outcome, using this system, to a statistically significant level. Unfortunately, this system enabled accurate classification with magnetic resonance imaging in only 7 of 33 (21%) labra, with the precision necessary to affect surgical planning in our series. We conclude that magnetic resonance imaging is not useful in the surgical planning for most patients with obvious anterior shoulder instability.

Arthroscopy↗
PubMedDate not supplied

Shoulder range of motion in elite tennis players. Effect of age and years of tournament play.

We studied glenohumeral rotational range of motion in 39 members of the United States Tennis Association National Tennis Team and touring professional program. We took goniometric measurements of internal and external rotation of dominant and nondominant shoulders at the glenohumeral joint with the humerus at 90 degrees of abduction. We categorized the tennis players by age and by years of tournament play. Results were analyzed by total rotation, internal rotation, external rotation, and dominant-to-nondominant shoulder differences. In our results, dominant internal rotation of the shoulder declined and the difference between dominant and nondominant internal rotation increased with both age and years of tournament play. Men and women tennis players showed the same degree of deficits in range of motion. Significant analysis of variance statistics were calculated for dominant internal rotation with years of total play, dominant total rotation with years of total play, and nondominant total rotation with age. Moderate negative correlations were found between dominant internal rotation and years of total play and dominant total rotation and years of total play. These results indicate a loss of internal rotation that seems progressive with longer periods of play. This loss of internal rotation of the shoulder is an absolute loss of motion because total rotation also decreases. Early detection and a corrective training program should be considered because adaptations may result in deleterious biomechanics affecting both performance and risk of injury.

Adaptation, Physiological↗
PubMedDate not supplied

Biomechanical performance of Bankart repairs in a human cadaveric shoulder model.

The objective of this study was to develop a method to evaluate the biomechanical performance of Bankart repairs in a human cadaveric shoulder in a clinically relevant orientation. Twenty fresh-frozen human cadaveric shoulder girdles were used to compare the biomechanical performance of intact anteroinferior capsulolabral complexes with the biomechanical performance of three Bankart lesion reconstruction techniques. Repairs were performed on surgically created Bankart lesions. Evaluations were performed with the shoulders in glenohumeral abduction and external rotation. The repair techniques employed interosseous sutures, Mitek GII suture anchors, or Acufex T-Fix devices. The suture material used in all repairs was No. 2 Ti-Cron. The biomechanical performance of the three reconstruction techniques did not differ, but each was significantly inferior compared with that of the intact shoulder samples. The interosseous repairs failed by suture pullout through soft tissue. Repairs in the Mitek GII group failed by pullout of the suture anchors, suture breakage, or pullout of the suture through soft tissue. Repairs in the T-Fix group failed by pullout of the suture through soft tissue or failure of the polymer portion of the T-Fix suture.

Biomechanical Phenomena↗
PubMed1984

The droopy shoulder syndrome.

We found that patients with thoracic outlet syndrome have: (1) low-set, "droopy" shoulders and long swan neck; (2) pain in the neck, shoulder, chest, arms, or hands; (3) aggravation of symptoms by downward traction and relief by propping up the arms; (4) occurrence in women; (5) absence of abnormal vascular, neurologic, and electrical findings; (6) a Tinel's sign over the brachial plexus; and (7) T-2 vertebra visible above the shoulders on lateral cervical spine films. In our experience, droopy shoulder syndrome has accounted for most cases of thoracic outlet syndrome but is largely unrecognized by physicians. Recognition of this syndrome should lead to a better understanding of the underlying pathophysiology and prevent unnecessary surgery.

Adult↗
PubMed2006

Accessory nerve to suprascapular nerve transfer to restore shoulder exorotation in otherwise spontaneously recovered obstetric brachial plexus lesions.

OBJECTIVE: A systematic follow-up of infants with an obstetric brachial plexus lesion of C5 and C6 or the superior trunk showing satisfactory spontaneous recovery of shoulder and arm function except for voluntary shoulder exorotation, who underwent an accessory to suprascapular nerve transfer to improve active shoulder exorotation, to evaluate for functional recovery, and to understand why other superior trunk functions spontaneously recover in contrast with exorotation. METHODS: In 54 children, an accessory to suprascapular nerve transfer was performed as a separate procedure at a mean age of 21.7 months. Follow-up examinations were conducted before and at 4, 8, 12, 24, and 36 months after operation and included scoring of shoulder exorotation and abduction. Intraoperative reactivity of spinatus muscles and additional needle electromyographic responses were registered after electrostimulation of suprascapular nerves. Histological examination of suprascapular nerves was performed. Trophy of spinatus muscles was followed by magnetic resonance imaging scanning. The influence of perinatal variables and results of ancillary investigations on outcome were evaluated. RESULTS: Exorotation improved from 70 degrees to functional levels exceeding 0 degrees, except in two patients. Abduction improved in 27 patients, with results of 90 degrees or more in 49 patients. Electromyography at 4 months did not show signs of denervation in 39 out of 40 patients. Intraoperative electrostimulation of suprascapular nerves elicited spinatus muscle reaction in 44 out of 48 patients. Histology of suprascapular nerves was normal. Preoperative magnetic resonance imaging scans showed only minor wasting of spinatus muscles in contrast with major wasting after successful operations. CONCLUSION: An accessory to suprascapular nerve transfer is effective to restore active exorotation when performed as the primary or a separate secondary procedure in children older than 10 months of age. Contradictory spontaneous recovery of other superior trunk functions and integrity of suprascapular nerves, as well as absence of spinatus muscle wasting direct to central nervous changes are possible main causes for the lack of exorotation.

Accessory Nerve↗
PubMedDate not supplied

Functional activities characteristics of shoulder complex movements: Exploration with a 3-D electromagnetic measurement system.

The high prevalence of shoulder-related dysfunction has focused increased attention on functional activity assessment. This study (1) tested the reliability of three-dimensional shoulder complex movements during four functional tasks representing different levels of task difficulty, (2) characterized the four functional tasks, and (3) examined the relationships between age and shoulder movements. Twenty-five asymptomatic subjects, all veterans aged 30-82, performed the four functional tasks. Good within-session reliability was found (movement pattern: similarity index = 0.81 to 0.97, peak values: intraclass correlation coefficients = 0.88 to 0.99). The raising arm to overhead height task (hard task) placed the greatest demand on scapular motions and humeral elevation (p < 0.005). During the functional tasks, significant correlations existed between age and scapular tipping, humeral elevation, and scapular upward rotation (r = -0.62 to 0.50, p < 0.05). Correlation results indicated that elderly subjects have a greater potential for serratus anterior muscle weakness and shoulder capsule tightness.

Adult↗
PubMed2001

Complications of thermal capsulorrhaphy of the shoulder.

BACKGROUND: The purpose of this study was to evaluate the rate of recurrence and the prevalence of complications related to the use of thermal energy for the treatment of glenohumeral instability. METHODS: A survey was conducted of all members of the American Shoulder and Elbow Surgeons, the Arthroscopy Association of North America, and the American Orthopaedic Society for Sports Medicine. The survey focused on the rate of recurrence, the number of axillary nerve injuries, and the prevalence of capsular insufficiency seen in revision surgery after thermal capsulorrhaphy of the shoulder. RESULTS: Three hundred and seventy-nine surgeons responded to the survey. Of 236,015 shoulder procedures performed over the last five years, 14,277 (6%) involved the use of thermal energy (1,077 involved laser energy; 9,013, monopolar radiofrequency; and 4,187, bipolar radiofrequency) for the treatment of glenohumeral instability. The rates of recurrent instability after laser, monopolar radiofrequency, and bipolar radiofrequency capsulorrhaphy were 8.4%, 8.3%, and 7.1%, respectively. Of the patients with recurrent instability, 363 (twenty-one treated with laser energy, 220 treated with monopolar radiofrequency, and 122 treated with bipolar radiofrequency) required revision surgery. In this group of patients with revision surgery, seven (33%) of the twenty-one treated primarily with laser energy, thirty-nine (18%) of the 220 treated primarily with monopolar radiofrequency, and twenty-five (20%) of the 122 treated primarily with bipolar radiofrequency exhibited signs of capsular attenuation at the time of the revision. A total of 196 patients (1.4%) (three treated with laser energy; 133, with monopolar radiofrequency; and sixty, with bipolar radiofrequency) had a postoperative axillary neuropathy; 93% of the 196 had a sensory deficit only. Of these patients, 95% recovered completely, with the sensory deficits lasting an average of 2.3 months and the combined deficits, an average of four months. CONCLUSIONS: The use of thermal energy for the treatment of shoulder instability has promising short-term results. The rates of recurrent instability are low. However, when recurrent instability occurs, capsular insufficiency may be present. Axillary nerve injury was reported in 1.4% of the patients, in most of whom it resolved spontaneously.

Adult↗
PubMed2001

Shoulder arthrodesis.

Current indications for shoulder arthrodesis include posttraumatic brachial plexus injuries, paralysis of the deltoid muscle and rotator cuff, chronic infection, failed revision arthroplasty, severe refractory instability, and bone deficiency following resection of a tumor in the proximal aspect of the humerus. The trapezius, levator scapulae, serratus anterior, and rhomboid muscles must be functional to optimize the functional result following shoulder arthrodesis. A consensus has not been reached concerning the ideal position of the shoulder arthrodesis, although excessive abduction or flexion has been associated with chronic postoperative pain. Decortication of both the acromiohumeral and the glenohumeral surfaces to increase the surface area available for arthrodesis is the most common means for obtaining successful fusion. Although there are numerous methods for stabilization of a shoulder arthrodesis, the most popular method today is probably the AO technique with either a single plate or double plates.

Arthrodesis↗
PubMed2006

Clinical assessment of three common tests for traumatic anterior shoulder instability.

BACKGROUND: Although traumatic anterior shoulder instability is common, the usefulness of various physical examination tests as tools for the diagnosis of this condition has been studied infrequently. We hypothesized that (1) such tests would be specific but not sensitive for this condition, (2) the usefulness of the anterior drawer test would be limited because of pain during the test, and (3) an anterior drawer test would be a useful adjunct for making the diagnosis if it reproduced the instability symptoms. METHODS: Between 2000 and 2004, 363 patients underwent a physical examination followed by shoulder arthroscopy. Forty-six patients with traumatic anterior shoulder instability that had been noted arthroscopically or documented radiographically after the trauma were included in our study group, and the remaining patients served as controls. The clinical usefulness of three tests (anterior apprehension, relocation, and anterior drawer tests) performed during the physical examination to make a diagnosis of traumatic anterior instability then was evaluated with statistical methods to assess their sensitivity, specificity, and likelihood ratios. RESULTS: If demonstration (or relief) of apprehension was used as the diagnostic criterion for a positive test, the sensitivity, specificity, and likelihood ratio were 72%, 96%, and 20.2, respectively, for the apprehension test and 81%, 92%, and 10.4, respectively, for the relocation test. If pain (or relief of pain) was used as the diagnostic criterion for a positive test, the values for the sensitivity, specificity, and likelihood ratio of both tests were lower. The anterior drawer test could be performed successfully in the physician's office for 87% of the patients. If reproduction of instability symptoms was used as the criterion for a positive anterior drawer test, the sensitivity, specificity, and likelihood ratio values of that test were 53%, 85%, and 3.6, respectively. CONCLUSIONS: The three physical examination tests for traumatic anterior shoulder instability are specific but not sensitive. Apprehension is a better criterion than pain for a positive apprehension or relocation test. The anterior drawer test (when pain does not prevent it from being performed) is helpful for diagnosing traumatic anterior instability. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions to Authors for a complete description of levels of evidence.

Adolescent↗
PubMed2006

Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients.

BACKGROUND: The prevalence and risk factors for recurrent instability and functional impairment following a primary glenohumeral dislocation remain poorly defined in younger patients. We performed a prospective cohort study to evaluate these outcomes. We also aimed to produce guidelines for the design of future clinical trials, assessing the efficacy of interventions designed to improve the outcome after a primary dislocation. METHODS: We performed a prospective cohort study of 252 patients ranging from fifteen to thirty-five years old who sustained an anterior glenohumeral dislocation and were treated with sling immobilization, followed by a physical therapy program. Patients received regular clinical follow-up to assess whether recurrent instability had developed. Functional assessments were made and were compared for two subgroups: those who had not had instability develop and those who had received operative stabilization to treat recurrent instability. RESULTS: On survival analysis, instability developed in 55.7% of the shoulders within the first two years after the primary dislocation and increased to 66.8% by the fifth year. The younger male patients were most at risk of instability, and 86.7% of all of the patients known to have recurrent instability had this complication develop within the first two years. A small but measurable degree of functional impairment was present at two years after the initial dislocation in most patients. Sample-size calculations revealed that a relatively small number of patients with a primary dislocation would be required in future clinical trials examining the effects of interventions designed to reduce the prevalence of recurrent instability and improve the functional outcome. CONCLUSIONS: Recurrent instability and deficits of shoulder function are common after primary nonoperative treatment of an anterior shoulder dislocation. There is substantial variation in the risk of instability, with younger males having the highest risk and females having a much lower risk. Future clinical trials to evaluate primary interventions should evaluate the prevalence of recurrent instability and functional deficits, with use of an assessment tool specifically for shoulder instability, during the first two years after the initial dislocation.

Adolescent↗
PubMed1995

Instability and impingement in the athlete's shoulder.

The competitive athlete who participates in a sport requiring overhead motion depends on a shoulder with optimal function. An acute episode of injury or a gradual onset of symptoms in the shoulder can affect the athlete's ability to perform. An understanding of shoulder anatomy and function is essential, and an accurate diagnosis of the underlying pathology is critical for planning treatment options. The correct diagnosis may be less clear when the athlete presents with an insidious onset of shoulder pain. A detailed history and physical examination, as well as an evaluation of the overhead motion and onset of pain, is important when the diagnosis of instability or impingement is considered. Rehabilitation of the rotator cuff often succeeds in alleviating symptoms and restoring function. Surgery is considered when symptoms and diminished function persist despite appropriate nonoperative treatment. Operative repair or reconstruction must be anatomical in nature. Postoperative rehabilitation is equally important in this setting, and a motivated athlete helps to ensure success.

Athletic Injuries↗
PubMed2001

Shoulder stiffness: a common adverse effect of HMG-CoA reductase inhibitors in women?

Muscle symptoms are known as adverse effects of HMG-CoA reductase inhibitors but their incidence is reported to be low. We treated a case of shoulder stiffness related to such a drug, which prompted us to preliminarily survey its incidence. We found that nearly one-tenth of women (6/66) taking such drugs reported drug-related shoulder stiffness. Shoulder stiffness is a very common symptom, while drug-induced shoulder stiffness is generally unknown. Many cases involving such an adverse effect may thus be overlooked. We present 2 typical cases here.

Aged↗