Rotator Cuff Index Measure Predicts Outcome of Nonsurgical Treatment for Rotator Cuff Tears

A recent study aimed to look at whether the outcome of nonoperative treatment of a rotator cuff tear could be predicted on the basis of the patient’s baseline clinical presentation. It additionally wanted to examine whether a successful outcome achieved after three months of treatment in a symptomatic full-thickness rotator cuff tear would be maintained at two years time. Rotator cuff pathology is among the most common causes of shoulder pain. The spectrum of this pathology can span from rotator cuff syndrome all the way to full thickness tearing. Decisions regarding treatment can be complicated as clinical symptoms may not always correlate with extent of damage or degeneration present on imaging. Many surgeons will choose to use an adequate course of nonoperative conservative management lasting at least three months before surgery is considered. However, there is no standard definition of what this “adequate” nonoperative treatment may consist of. Additionally, this may differ from one patient to the next.

The dependent variable used in the prospective cohort study mentioned above, was the outcome of nonoperative treatment classified as either success or failure at the patient’s three-month follow up appointment. Successful treatment was defined that surgery was no longer deemed appropriate by both the patient and the surgeon as the patient demonstrated considerable improvement and was predominantly asymptomatic. If the patient elected to schedule surgery the nonoperative treatment was deemed to have failed. Ten clinical baseline measurements were utilized and examined for their predictive ability. Examples of these baseline measures include age, sex, duration, onset, strength, range of motion, and Rotator Cuff Index Measure. Originally 104 patients met the inclusion and exclusion criteria. Each participant had a documented chronic full-thickness rotator cuff tear and underwent a series of five visits including two with a sports medicine physician, two with a physiotherapist, and one with an orthopedic surgeon. The rehabilitation program included stretching and strengthening exercises. At three months time the patient was scheduled to meet with the orthopedic surgeon whom they had originally been assigned to. After examination, the surgeon classified the outcome of rehabilitation as either a success or failure. The Rotator Cuff Quality-of-Life Index (RC-QOL) instrument was administered at the patient’s first visit, again on arrival at their three-month surgical consultation and then again twenty-four months after their initial baseline assessment. It should be noted that both the sports medicine physician and orthopedic surgeon were blinded to the RC-QOL results.

For analysis, patients were grouped on the basis of outcome of their nonoperative treatment, and the ability to predict this outcome on the basis of the baseline characteristics. Of the original 104 patients ninety-three were analyzed. Seventy five percent of the patients were classified as having a successful outcome at their three-month consultation visit. It was found that the only baseline characteristic that was significant in prediction of success or failure in the analysis was the RC-QOL. Two-year follow up demonstrated that eighty nine percent of the patients maintained their three-month outcome (success or failure). The authors of this article believe these results demonstrate that the RC-QOL can be utilized to determine whether the patient is likely to have a successful or failed outcome in a course of nonoperative treatment.

Review of Management Strategies for Acute Shoulder Dislocations

Due to a scarcity of bony restraints and minimal articular contact the shoulder joint has the greatest range of motion of any joint in the body. It relies on soft-tissue restraints for stability, including the capsule, musculature and ligaments. Because of this, the shoulder joint is at high risk for dislocation. There are many shoulder dislocation reduction techniques. Many of these have been described in the literature, however, there is lack of comparative studies on the various techniques. It is essential that there be thorough understanding of anatomy, classification of the dislocation, type of reduction maneuver and different anesthetic technique for successful management of this injury.

The shoulder joint is held in a reduced position through both static and dynamic stabilizers. Static stabilizers include the glenoid fossa, labrum, capsule and glenohumeral ligaments. They work by maintaining the continuity of the joint through reinforcing support at end ranges of motion. For example, the labrum increases shoulder stability by contributing 50 per cent of the glenoid cavity depth and increasing the total surface area. The glenohumeral ligaments resist translation. Dynamic stabilizers include the deltoid, biceps, rotator cuff and scapular stabilizing muscles. They function via the neuromuscular system by actively stabilizing the moving joint at mid ranges of motion. For example, the rotator cuff provides a dynamic compression of the humeral head into the fossa of the shoulder joint. The trapezius, rhomboids, latissimus dorsi, serratus anterior and levator scapulae muscles actively stabilize the scapula to allow for increased stability. Shoulder dislocations are classified as either traumatic or atraumatic. They are further classified by the direction of dislocation either anterior, posterior or inferior. Anterior shoulder dislocation is the most common at ninety seven percent.

Despite that there are multiple reduction maneuvers available some general principles apply to acute management of shoulder dislocations. A dislocation should be reduced as quickly as possible to avoid muscular spasms and neurovascular compromise and it’s important that all of this should be done in a gentle and technically sound closed reduction process. If the reduction is tended to quickly before muscular spasm sets in, often it can be done without local pain medication. Anesthesia may be required and it is recommended that intra-articular block be used first, while reserving sedation for the more difficult cases. Like mentioned previously, multiple reduction techniques exist. For anterior dislocations popular reduction methods include: Hippocrates, Traction-countertraction, Chair, Kocher, Stimpson, Milch, External Rotation, Spaso, Eskimo, Scapular Manipulation and FARES (Fast, Reliable and Safe). Posterior dislocations are less common occurring only three percent of the time and are often more difficult to diagnose. Closed reductions are often difficult and may require at least two operators and sedation. Inferior shoulder dislocations are even more rare, occurring less than one percent of all dislocations. Two different reduction methods are used in inferior dislocation management known as Traction-Countertraction and Two-step.

Only a few studies have looked at and compared different methods of closed reduction. In a study of 111 patients, the Milch and Kocher techniques were compared. They found no difference between the two in success rate but the Milch technique was found to be more successful in patients over forty years of age when performed within a timeframe of four hours of dislocation. In a randomized study with patients who suffered anterior dislocation were treated with either the Stimson or Milch technique. With the Milch technique success rate was 82 per cent on first reduction compared to only 28 per cent for the Stimson technique. Another randomized control trial of 154 patients with anterior dislocation demonstrated that the FARES method was more successful, quicker and less painful than the Kocher and Hippocrates techniques. After successful reduction, rehabilitation usually occurs to maximize range of motion and to regain stability. There is usually a minimum period of immobilization lasting three to four weeks. Gradual return to activity will be achieved after this.

The authors of this review conclude that while there are many methods for management of acute dislocation, the orthopedic surgeon must be well versed in different techniques to best decide the appropriate approach for each individual patient.

Do Frozen Shoulder and Rotator Cuff Injuries Go Together?

Shoulder injuries are pretty common, but there is one that is especially frustrating because it seems to come on out of no where, frozen shoulder. Frozen shoulder is known in the medical field as adhesive capsulitis and presents as a loss of range of motion (ROM) with no known cause. This definition is quite broad and many people fall into this category. Many researchers and physicians have recently reported that rotator cuff (RTC) injuries can be quite common with frozen shoulder and some even believe that a RTC injury may be the cause of a frozen shoulder. However, due to the vagueness of the definition many studies about frozen shoulder use very different criteria for the loss of ROM, and this makes these studies hard to compare. This study by Ueda et al hopes to clarify the symptoms of people with frozen shoulder who also have a rotator cuff injury.

This study consisted of 379 shoulders of patients with stiff shoulders with no trauma, diabetes or other abnormalities. Their ROM was measured in standing and lying down and the shoulders were divided into three groups. Group 1 had severe and global loss of motion in all three directions, less than 100 degrees of forward flexion, less than 10 degrees of external rotation and internal rotation reach no higher than the level of the 5th lumbar vertebra. Group 2 had severe limitation in at least one of the three directions, but not in the other two. The 3rd group included all the remaining shoulders with mild to moderate limitation. These shoulders were then imaged with MRI or ultrasound to determine if there was injury to the RTC.

Group 1 had eighty-nine stiff shoulders with mean ROM measurements of forward flexion of 88 degrees, external rotation of 1 degree and internal rotation reach just to the buttock level. The imaging studies showed that ninety-one percent had no injury to the RTC and nine percent had a partial tear. There were no full thickness tears in this group at all.

Group 2 consisted of 111 stiff shoulders with mean ROM measurements of 130 degrees of forward flexion, 31 degrees of external rotation, and internal rotation reach to the 5th lumbar vertebra. The imaging results of this group showed forty-four percent normal RTC, seventeen percent partial-thickness tear and thirty-nine percent had a full thickness tear of the RTC.

Group 3 included 179 stiff shoulders with mean ROM measurements of 154 degrees of forward flexion, 49 degrees of external rotation and internal rotation reach to the 12th thoracic vertebra. The imaging studies showed thirty-five percent normal RTC, sixteen percent partial tear, and fifty percent with a full thickness tear in the RTC.

The results of this study indicate that if there is global and severe loss of motion with a stiff shoulder, then it is not likely that there is a rotator cuff injury. However if there is loss of motion in only direction, but not as severe in the others, or only minimal loss of motion in all directions there can be up to a 50 per cent chance of a full thickness rotator cuff tear. In this case, getting imaging such as an MRI to look at the RTC is appropriate.

Calcific Tendonitis is Best Treated Conservatively

Calcific tendonitis occurs when tiny deposits of calcium form on or in a tendon, which then can result in pain and inflammation.  While this can be caused by a number of things, such as poor body mechanics or hypothyroidism, it typically affects people between 30 and 60 years old and more females are affected than males. Frequently these calcium deposits occur on the rotator cuff tendons surrounding the shoulder joint.

The exact reason why these calcium deposits appear is still being argued. The current leading theory is that normal cells in the tendon are replaced by abnormal cells, which is kick started by tendon misuse and abuse. Once the tendon is stressed, the process towards calcific tendonitis is classified into three phases: precalcific state, calcific state, and postcalcific state. This process is often cyclical with the postcalcific state including a return to a normal tendon.

Calcific tendonitis symptoms include primarily pain and a decrease in shoulder motion and strength. X-rays, MRIs, and ultrasounds are often used for diagnosis. Typically the tendonitis is managed without surgery and includes anti-inflammatory medication, physical therapy, and corticosteroid injections. Other conservative and promising treatment options include extracorporeal shock wave therapy and ultrasound-guided needle lavage. Extracorporeal shock wave therapy involves pulses of waves used to blast the calcifications. An ultrasound-guided needle lavage includes a needle inserted adjacent to the calcium deposit with an injection of a saline and anesthetic mixture and a continual flushing of the tissue until the calcification material no longer comes out. However, research for each of these newer treatments has yet to delineate specific effective techniques.

Surgery is reserved for calcific tendonitis that does not respond to conservative methods. Techniques are controversial and have mixed reviews in the literature.

The lead author of a recent review of all available research for treatment and outcomes of people with calcific tendonitis of the rotator cuff concluded that all patients should initially be treated conservatively and informed of the natural progression of the disease. Health providers should emphasize that typically the most pain and tendon inflammation occurs during the re-absorptive state of the calcium deposit, prior to return to fairly normal healthy tendon. Conservative treatment should last three to six months prior to seeking other help. If three months passes without relief, then ultrasound-guided needle lavage is recommended. If this does not work, then at the six-month mark surgery, specifically an arthroscopic decompression is recommended followed by physical therapy.

Treatment Options for Upper Arm Bone Fractures

Four to five per cent of all reported fractures are upper arm bone (humerus) fractures, most frequently occurring in the elderly population from falls.  If the fracture is “non-displaced,” or the bone is still aligned after the break, the bone is simply immobilized for a period of healing time.  If the bone is “mal-aligned” or no longer lining up to the point that it can heal itself, then a decision must be made whether to have a surgical correction or to allow the bone to remain the way it is.  A mal-aligned humeral head (the ball part of shoulder joint) poses difficulty for surgical correction because of the numerous angles that must be accounted for at the shoulder joint, all of the muscles that attach and function surrounding it, and because an offset humeral head can pinch structures like nerves and blood vessels traveling by it during arm movements.

Elderly people who are not high functioning and do not have pain can do ok with malunions without corrective surgery. Broadly speaking, higher functioning individuals and the younger population have two surgical choices: to either preserve the joint (keep the humeral head) or to have a shoulder replacement (take off the humeral head and replace it with metal).  This decision is made depending on the individual and type of mal-union present. The surgical goal is to improve a person’s quality of life and restore as much function as possible, but not necessarily return the person to their previous state of function as this often proves too surgically difficult.   

Joint preservation is appropriate when there are two adjacent surfaces on the bone that can be put back together with hardware and there still is good blood supply to the humeral head. It is often challenging to determine what specifically is causing the pain at the site of the mal-union– the poorly healed bone itself, soft tissue (like tendons or muscles), or a boney protuberance.  All of the contributing factors need to be addressed for good outcomes and joint preservation techniques address these.

Joint replacement is appropriate when there is a good chance of humeral head bone death due to a poor blood supply.  Shoulder joint replacements remain complex even for the most skilled surgeons and the jury is still out on what type of shoulder replacement is most appropriate. The three main options are a partial humeral head replacement, a total humeral head replacement with normal anatomical alignment, or a total humeral head replacement with a reverse alignment from anatomical placement.

Failed SLAP Repair Management

Typically, arthroscopic repair of SLAP (superior labrum anterior-posterior) shoulder lesions tend to produce good outcomes. However, there is a small amount of patients that continue to have pain, symptoms or suffer further injury after this repair and may seek additional treatment. A recent review wanted to investigate what the research demonstrates in management of patients whom have suffered a failed SLAP repair.

SLAP tears are a detachment of the superior glenoid labrum from anterior to posterior with or without involvement of the biceps head. Substantial variability exists in methods for diagnosis of these tears including use of orthopedic special tests, MRI (magnetic resonance imaging) and MRA (magnetic resonance arthrogram). Initial treatment usually consists of conservative management including physical therapy, anti-inflammatory agents and activity modification. When non-operative management fails, surgery may be indicated based on a variety of factors. As mentioned earlier these surgical outcomes generally fare well. However, if patients continue to have pain or symptoms following repair it’s important that a thorough workup be performed as the cause can be multifactorial. Differential injections into the subacromial and/or glenohumeral region can be utilized for diagnostic or therapeutic workup and physical therapy can be used for ROM (range of motion) and strengthening. According to the authors of this review, if pain and postoperative stiffness do not resolve with nonsurgical measures, this is defined as a failed SLAP repair. They concluded that recurrent injury secondary to return to the precipitating activity, misdiagnosis, and poor healing are the main causes of failed SLAP repair.

Management of failed SLAP repair can be nonsurgical or surgical. The authors of this review emphasize nonsurgical treatment particularly for overhead throwing athlete as satisfactory outcomes associated with revision have not been conclusively proven in the literature. Rotator cuff strengthening, proper throwing mechanics and physical therapy for ROM are emphasized. Surgical outcomes for failed SLAP repair include revision SLAP repair, and biceps tenotomy(long head of the biceps tendon is released from its attachment) or tenodesis (reattachment of the biceps tendon to the humerus) with or without revision SLAP repair. Revision SLAP repair were deemed most appropriate for young (aged <35 years), active patients without obvious pathology of the long head of the biceps tendon. It was shown that revision SLAP repair were inferior to those of primary repair. Biceps tenodesis is deemed most appropriate for middle aged patients, women and younger patients with known pathology of the biceps tendon. In patients over 65 tenotomy was preferred. It was suggested that select patients with failed type II SLAP repairs that biceps tenodesis may provide safe and effective treatment for failed SLAP repair. Otherwise, data reported demonstrates outcomes that surgical management of failed SLAP repairs are inferior to those of primary repair.

Stabilization for an Unstable Shoulder.

The operative management for traumatic anterior shoulder instability has changed from open to arthroscopic techniques. Even though the surgical procedure has evolved there is still controversy over the results of open or arthroscopic shoulder stabilization. Advantages of arthroscopy are faster recovery, less postoperative pain, decreased operative time. improved cosmetic appearance, improved shoulder range of motion and more accurate identification of problems within the joint. Those that favor open procedures cite superior long-term results with fewer recurrences. This study wanted to find out the quality of life at two years, as measured by the Western Ontario Shoulder Instability Index (WOSI).(The WOSI is a tool form designed for self-assessment of shoulder function for people with instability).

In this study, dominant and non-dominant shoulders were operated on depending on the injured side. The time from injury to repair went up to 75 months. The average age of the patient was about 20 years old to 36 years old and both males and females underwent surgery.

In the post-operative findings, the WOSI scores improved significantly in both groups form baseline to two years after the either operation. On average there were slightly higher scores in the arthroscopic group but they were not significantly higher. Range of motion between the two procedures was similar between groups, with the arthroscopic repair group having slightly less outward rotation of the shoulder. An important finding was in the rate of recurrent instability was significantly lower in the open group than the arthroscopic group. At two years the difference in quality of life between the patients in the two groups was similar.

In the study a higher complication rate was found in the open surgery, but all patients recovered from the complications (transient nerve dysfunction and infections). Data in this study suggests a patient profile that is more likely to experience recurrent instability after surgery: male, twenty-five years old or younger, has a Hills-Sachs lesion ( an injury to the head of the bone of the arm). The study recommends considering an open repair for this group.

There was no significant difference that was found in quality of life between the patients who were operated on, as measured by the WOSI. The information in this study suggests that open repair may be recommended to reduce recurrent instability in younger male patients with a Hills-Sachs lesion.

An Overview of the Complications of Shoulder Arthroscopy

Shoulder arthroscopic surgery has become more utilized than open shoulder surgery over the past 20 years, with many citing fewer complications as a reason for the shift in treatment.  However, after a review of the available evidence, Dr. Moen and his colleagues found that complications of arthroscopic surgery are not less devastating or prevalent than those of open joint surgery, they are simply different.

Arthroscopic surgery is performed by inserting instruments into a joint through small portals.  Surgeons use small video cameras and tiny instruments to minimize joint disruption while they are repairing the joint.  Prior to this technology, surgery was always open, with the skin, being cut back, muscles pulled aside, and the joint exposed for repair.  

Surgical complications exist in three stages: prior to the surgery, during the surgery, and after the surgery.  Prior to the surgery several things must be considered. The underlying patient pathology should be first taken into account.  Certain procedures are best repaired with an open technique and others with an arthroscopic technique and if the wrong technique is used it can further subject the patient to problems down the road. Surgeon’s skill level and history with performing the indicated repair with an open or arthroscopic technique is another careful consideration.  But, the highest probability for complication with arthroscopic surgery is choice of patient position during the surgery.

There are two main positions used for shoulder surgery.  Bench position resembles sitting up in a recliner.  Lateral decubitis position is the patient laying on their side with their injured shoulder facing up with the arm held away from the body by a special sling.  Precautions for both of these positions include the standard ones for any surgery.  The longer a body is held in a certain position, the greater the chance for skin breakdown and joint injury so the patient is carefully positioned and padded. If an extremity is wrongly positioned or held down too tightly nerves and blood supply can be negatively affected.  Specifically, the head and neck must be carefully positioned and held in a neutral alignment to avoid risk of stroke or brachial plexus. This is especially true for the bench position as the patient is vertical and the neck could easily fall to the side. In the lateral decubitis position there is an increased risk for lower leg nerve injury because of the pressure on the side of the leg, and brachial plexus injury because the patient’s shoulder is under a certain amount of traction.  Studies reviewed found the best arm placement for visualization to be 25-30 degrees of abduction (away from the patient’s side) and 30 degrees of forward flexion (in front of the body), with a decreased risk of brachial plexus injury with the arm positioned at either zero or 90 degrees of abduction and 45 degrees forward flexion with the least amount of traction required to complete the procedure. Authors strongly suggest that the surgeon be involved in the positioning of the patient to avoid foreseeable complications.  

During the operation many nerves are vulnerable to injury.  The portal site placement, or the holes through which the instruments pass, is crucial in that the nerves are avoided. The three main nerves at risk to direct injury are the axillary, musculocutaneous, and subscapular nerves. Certain surgical procedures present a greater risk to certain nerves, however each procedure follows specific precautions to decrease chance of injury. Another intraoperational complication, though rare, is a neurological event.  These very serious events can include damage to nerves in the neck or eye nerves as well as venous air embolisms (an air bubble is introduced into the venous system and often results in death).  

The most looked at serious complications of arthroscopic surgery are ischemic events where blood fails to flow where it should resulting in stroke, central nervous system cell death, and vision loss. Typically these events occur when the patient is placed in the seated “bench” position during surgery.  When a person is awake, the nervous system regulates blood pressure, assuring blood is flowing to where it should.  General anesthesia depresses this blood pressure regulation and the system can fail. Surgeons and anesthesiologists can mitigate the ischemic events by carefully monitoring blood pressure, applying regional or intravenous anesthesia, or performing the surgery in the less risky side-lying position.

Postoperative complications include joint infections and thromboembolic events (when a blood clot forms, breaks away, and moves to another area to block a blood vessels). Arthroscopy itself has a very low rate of infection, however the infection risk increases significantly with a transition to an open procedure during an arthroscopy. This infection risk is lowered by proper sanitization of surgical instruments, proper preparation of the patient’s skin and glove changing prior to conversion to an open surgery, and the patient taking antibiotics prior to the surgery. Thromboembolic events are rare for arthroscopic surgery and therefore have little evidence to investigate procedures for their prevention.

Even though arthroscopic surgery is rapidly becoming the method of choice for shoulder patients, there are surgical complications that must be considered.  These complications can be minimized by careful patient selection, proper choice of surgical technique (open versus arthroscopic), the patient’s position during surgery, thorough knowledge of shoulder anatomy, and careful use of anesthesia.

An Option for Sternoclavicular Joint Reconstruction

Pain and dysfunction of the sternoclavicular (SC) joint, which is where the collar bone attaches to the sternum, is rare but can be quite problematic. This joint is important for normal arm movements and when it becomes unstable it is usually in the anterior direction. Excess movement here is usually the result of a traumatic event but can also be due to degenerative changes, or general laxity. There are several surgical techniques in use if conservative treatment is not effective, and this study looks at the results of one of these techniques. The specific technique researched in this study uses the tendon of the sternocleidomastoid (SCM) muscle to anchor the collar bone to the sternum.

This technique takes a part of the tendon from a large neck muscle, the SCM, loops it through a tunnel created in the end of the collar bone and then anchors it down to the sternum. The purpose is to provide stability to prevent excess movement, pain and dysfunction of the arm.

In this retrospective study there were thirty-two patients who underwent this surgery from 2005-2010. Fourteen patients had pain in the SC joint following a traumatic event, mean age twenty four; seven presented with generalized laxity, mean age of twenty three; and eleven had evidence of osteoarthritis mean age of fifty one. The duration of symptoms prior to surgery for all the patients was over two years, for the patients with degenerative changes it was just over four years and for the patients with hyper laxity they had symptoms for over six years before surgery. All patients were followed for forty-four months following their procedure.

The clinical scores and the pain rating for all three groups improved significantly and to the same extent for each group. There was persistent instability in two patients, both of which declined further intervention. There were no other complications reported.

Numerous surgical techniques for treatment of this problem have been described in the literature, but this is the largest study performed on one single technique to date. Fortunately it appears that this is a highly successful technique, with good clinical and functional outcomes and minimal to no complications. This technique also appears to be equally effective for the multiple causes of SC joint pain. The results of this study suggest that SC joint reconstruction with the SCM tendon graft is a safe and reliable technique for patients with debilitating instability at the SC joint.

Diagnosis and Treatment of Scapular Winging

Scapular dyskinesia is a term used to describe poor movement patterns of the shoulder blade. The shoulder blade, or scapula, moves in multiple planes and must be coordinated with the glenohumeral joint in order to allow full range of motion of the shoulder. When the length, strength or timing for firing the scapular stabilizing musculature is not optimal, scapular dyskinesia occurs. One type of scapular dyskinesia is winging of the scapulae.

Scapular winging can result from either weakness or stiffness of multiple muscle groups, including serratus anterior, trapezius, rhomboid major and minor, and/or levator scapulae. Of these muscles, serratus anterior is the most common muscle contributing to winging. It is a flat muscle that originates on the upper eight or nine ribs and inserts on the medial border of the scapula. Its primary action is to stabilize the scapula against the rib cage, then laterally rotate the inferior angle of the scapula during overhead activity. The trapezius muscle may also be involved with scapular winging. This muscle helps retract, elevate and rotate the scapula and is most often injured with surgeries in the cervical area. A third muscle group that may be involved is the rhomboid major and minor, which together retract, elevate and medially retract the inferior angle of the scapula. Injury to these muscles can be a result of entrapment of the C5 nerve under a hypertrophied scalene muscle.

As previously mentioned, the cause of scapular dyskinesia is a muscle imbalance of the scapular stabilizers that can either be neurogenic in nature or inherently muscular. With scapular winging in particular, traction or stretch injuries to the long thoracic nerve can be a primary cause. The long thoracic nerve passes between the anterior and middle scalenes then travels along the chest wall to the serratus anterior. Positions in overhead sports can easily stretch the long thoracic nerve resulting in repetitive or traumatic stretch injuries to the nerve and resulting in neuropraxia that inhibits the serratus anterior. Neuropraxia can occur with increases in nerve length of only ten per cent. Aside from long thoracic nerve injuries, spinal accessory nerve injury can also lead to scapular winging as it inhibits trapezius muscle activity.

Iatrogenic injuries to the long thoracic nerve or spinal accessory nerves can also occur. These may include invasive procedures such as first rib resections, lymph node biopsy, mastectomy, surgical treatment for pneumothorax and infraclavicular plexus anathesia. Atraumatic causes of scapular winging may include Arnold Chiari malformation, Guillian Barre syndrome, lupus, and Lyme disease, all of which can cause shoulder girdle weakness.

The clinical presentation of an individual with scapular winging typically includes report of posterior shoulder pain that may radiate down the arm or up the neck. The pain can either be associated with an event or insidious in nature. The individual may experience loss of range of motion into forward flexion or abduction, weakness and a sensation or clicking or catching of the shoulder joint with movement. A skilled clinician will look at scapular position at rest and identify any scapular dyskinesia present with active range of motion of the shoulder or weight bearing on hands in a push up type position. A patient with serratus anterior palsy with exhibit winging at rest and may have pain at rest in periscapular muscles that are attempting to compensate for the weak serratus. Winging is typically accentuated in a wall push up position. If trapezius palsy is involved, wasting or atrophy of the muscle will be visible at the neckline and shoulder drooping will be present. Weakness will be present in overhead positions and winging will become apparent with resisted abduction or external rotation. Winging associated with rhomboid dysfunction is the most difficult to identify. Patients may report medial scapular pain and demonstrate mild winging at rest that increases as they lower their arms from forward flexion.

With many possible causes and clinical presentations, the incidence and prevalence of scapular winging is unknown as it is often misdiagnosed. Common misdiagnoses include rotator cuff tendinopathy, shoulder instability, cervical radiculopathy, acromioclavicular joint disorders and nerve disorders. EMG testing is the only definitive diagnosis for serratus anterior, trapezius, rhomboid and levator scapulae dysfunction that may contribute to scapular winging, however the extent of nerve damage or recovery potential cannot be identified unless serial EMG tests are performed. Furthermore, it is important to understand that patients presenting with symptomatic winging may not show EMG dysfunction, thus clinical findings are equally as important. Identifying scapular dyskinesias and the muscle length and strength relationships involved is key to proper diagnosis of scapular syndromes. More importantly, early identification of scapular winging as a component of shoulder dysfunction is important for maximizing outcomes and minimizing continued pain or secondary injury to the shoulder.

Nonoperative treatment is the most common for scapular winging, whether the cause be neurogenic, muscular, or both. Physical therapy should focus on range of motion and periscapular strengthening to correct scapular winging associated with serratus anterior, trapezius, rhomboid and/or levator scapulae imbalance . Palsies are also initially treated conservatively with the same physical therapy focus. Traumatic serratus anterior palsies typically resolve in six to nine months, nontraumatic palsies may take up to twenty four months. Chronic palsies that do not resolve with conservative care can be treated with surgical techniques including muscle transfer from the sternal head of the pectoralis major to the inferior scapular pole, facial grafts, slings, and scapular fusion to the rib cage. Trapezius palsy, though initially treated similarly to serratus palsy with conservative physical therapy treatment, does not have the same success rate with recovery. Maximum function is typically gained after just one year of conservative physical therapy, after which surgical techniques are considered. The Eden Lange dynamic muscle transfer procedure involves using rhomboid major and minor and levator scapulae to mimic the trapezius muscle function. Success rates are relatively high for improving function and decreasing pain, ranging from 71 to 92 per cent. Nerve transfer procedures can also be performed for iatrogenic or traumatic spinal accessory nerve injury.

Recognizing and Repairing a Rotator Cuff Tear

Your rotator cuff is comprised of 4 muscles the supraspinatus, infraspinatus, teres minor and subscapularis. The muscles attach to the bones via tendons. They are responsible for motor control and stability of the shoulder and are active in every motion of the shoulder. Rotator cuff tears happen when one or all of the tendons in the shoulder are torn away from their attachment to the head of the long bone of the arm in the shoulder joint. These tears can cause a significant degree of pain and loss of function. Surgical repair is sometimes necessary to reduce pain and regain the function of the shoulder. With advancements in imaging of the body and surgical techniques rotator cuff tears are now better recognized, classified and treated. This allows a more planned and precise surgery and hopefully and more accurate prognosis.

A high quality MRI can be used to predict specific tear patterns that will be encountered in arthroscopy. Studies have been done that now allow surgeons to detect three-dimensional tear patterns using high-resolution MRI, select an appropriate repair method and estimate prognosis at a consultation visit before entering the surgical site. Three-dimensional tear pattern recognition is used to as a standard method of evaluation in patients with posterosuperior rotator cuff tears. However, arthroscopy still allows for better visualization than an MRI.

When a repair is being performed the reestablishment of the normal anatomy is the goal as it is thought to enhance healing and restore normal muscle function. When a rotator cuff tear is present it is classified in multiple planes because of the three-dimensional recognition. The recognition of tears takes into account the anterior-posterior dimension (front to back), how much the tendon is retracted from the normal site of attachment, number of muscle/tendon tears, health of the muscle/tendon. The classifications are: crescent tears, U-or L-shaped, massive, contracted, and immobile. The prognosis of each depends on the above factors and is something that will vary.

Repair techniques will depend on the surgeon and all of the above qualities that a rotator cuff tear can have. Repairs can be full or partial, have one or two rows of sutures and use different anchoring or fixation methods. The goal though of any repair is to obtain the best functional outcome that is possible taking into consideration the quality of the rotator cuff tear.

A Review of Factors Affecting Rotator Cuff Healing

A review of current literature identified positive and negative factors regarding rotator cuff repair healing.  Negative healing factors include larger tears, excessive fatty tissue in the repair, muscle atrophy (or lack of muscle mass), and older age due to a poor healing environment.  Factors that do not affect healing outcomes are the type of surgical technique used or the use of platelet-rich plasma.  Evidence is conflicting for the type of rehabilitative postoperative protocol used.   

The shoulder joint is a complex joint, which consists of your arm bone (humerus), collarbone, and shoulder blade.  These three bones are linked together via ligaments, tendons, and a thick fibrous capsule.  The amount of boney congruency is likened to a golf ball (the head of the humerus) on a tee (the scapula).  This lack of bony contact allows us to move our arms in a circle but at the same time sacrifices joint stability. Instead of relying on bone to help hold the joint together, the shoulder joint must rely on six “rotator cuff” muscles and tendons as well as a capsule surrounding the joint made up of thick fibrous tissue.

Authors point out that rotator cuff repair studies often focus on patient functional outcomes versus actual healing and that these two factors do not always go hand in hand. Functional outcomes, or the return to doing what you want to do, are often measured by questionnaires.  Pain, motion, and strength are also considered in gauging effectiveness of surgery.  The actual tendon healing, however, is often overlooked.  The amount of tendon healing can be seen with imaging, such as an MRI.

The extent of the tendon healing depends on numerous factors.  The proper surgical technique is debated among surgeons.  Incision type can be either open (large incision) or arthroscopic (small incision). Because this review simply looked at the tendon healing, it found that there was no difference between the two.  Surgeons have the option to perform either a single row stitch or a double row stitch on the tendon for the repair, depending on the type and size of the tear.  The failure rate for a single row stitch is slightly higher than that of a double row stitch, but the data is considered “not statistically significant,” meaning that there might be some factors unaccounted for that may make these numbers misleading. Tying knots or not tying knots in the stitch is yet another technique controversy that goes unanswered with regard to tendon healing.  Another review did find unknotted sutures to be slightly more beneficial from a shoulder movement standpoint. Suture anchors, or the piece of material that holds the suture to the bone, have yet to be examined for their contribution to tendon healing. The preparation of the bone for the anchor attachment is also a factor and some worry that it can interfere with the anchor integrity in bones that are osteoporotic, or brittle. Studies show that there is slightly better healing with a microfracture technique (tiny holes are poked in the bone to encourage healing), than the standard procedure. Platelet-rich plasma (PRP), or blood components thought to speed up healing, is sometimes injected at the site of the repair. Multiple studies show no benefit of this towards healing and that it can actually increase the chance of infection.  

Often in a shoulder that has difficulty with stability, an extra piece of bone builds up on part of the shoulder blade, called an acromial bone spur.  Sometimes this spur is removed during the rotator cuff repair.  Authors found that whether or not the spur is removed during the rotator cuff surgery healing of the rotator cuff is not affected.  Likewise, a person’s anatomy can predispose them to a rotator cuff problem and surgeons can “fix” these by changing the direction of the pull of the tendons with an “augmentation patch.” However, at this time evidence is controversial whether or not they help with the healing process for rotator cuff repair, with the bulk of the evidence suggesting not using them.

Surgical techniques aside, there have varying opinions on what rehabilitative protocol, or recipe, to use following surgery.  Two common camps are early movement after surgery versus delayed movement but there is no great evidence to support faster healing times with either.  There are several patient factors that significantly effect healing time, including increase in age, the size and location of the tear, the quality of the tissue, how long prior to surgery the tear occurred, and the presence of osteoporosis and diabetes.

Overall, rotator cuff healing is affected by a number of variables.  The exact combination of factors has yet to be determined.  Authors point out as well that readers should keep in mind that there factors that are unaccounted for in this review such as pain levels, outcomes, speed and ease of procedure and postoperative complications.  

Rotator Cuff Repair and Immobilization

Shoulder rotator cuff repair aims to suture torn rotator cuff tendons and provide them with the optimal environment to heal and minimize chance of retear. Overall retear rates have decreased over the years, but are still a major concern. Better suture techniques have been thoroughly investigated but there is less attention paid to the rehabilitation protocol. Currently the gold standard for rehabilitation after surgery is to wear an abduction brace and begin physical therapy for passive range of motion within the first few weeks. As surgical techniques have evolved from open surgery to arthroscopic surgery, there are questions as to whether this rehabilitation protocol is ideal. Animal studies have shown that longer periods of immobilization are beneficial to healing after rotator cuff repair.

A recent study published in The Journal of Bone and Joint Surgery investigated the effectiveness of immobilization after surgery in human subjects. The goal was to determine if longer periods of immobilization resulted in any clinical differences in outcomes, including shoulder range of motion, retear rates and clinical outcome scores. One hundred participants who met specific criteria and underwent arthroscopic repair of the rotator cuff were randomly sorted into two groups. One group was immobilized after surgery for four weeks, the other was immobilized for eight weeks. After the allotted time of immobilization each participant underwent rehabilitation with a physical therapist that included passive range of motion then progressed to active range of motion and strengthening.

At follow up conducted at six months and 24 months after surgery, there were no statistical differences between the groups with retear rates, passive range of motion or clinical scores. There were more reports of stiffness by participants who were immobilized for eight weeks compared to those immobilized for 4 weeks. Patients were also less likely to adhere to the immobilization guidelines for a full eight weeks compared to those immobilized for four weeks. With no benefit in healing or diminished retear rate gained by immobilization for eight weeks, it is deemed most beneficial to promote immobilization for four weeks after rotator cuff repair. The retear rate in this study was 10 per cent, compared to previously reported rates of 20 per cent to 40 per cent in studies that involved early passive range of motion before four weeks. Thus a four week immobilization period may give the rotator cuff ample time to heal without increased stiffness and decrease retear rates.

Common Injuries and Treatment Options for the Adult Shoulder

The shoulder is one of the most mobile joints and most complex joints in the human body. It moves in no less than seven planes if you consider only movement at the glenohumeral joint. If you then take into consideration that the shoulder also involves the acromioclavicular and sternoclavicular joints as well as the scapula, the movement becomes even more complex. It is essential that the shoulder joint be controlled by well balanced muscles that control each of the aforementioned joints and the scapula, particularly in athletes that rely on shoudler strength and mobility for their sport. As the shoulder ages, well balanced movement becomes harder to achieve, presenting a challenge in injury prevention and treatment. The three most common shoulder diagnosis in the aging shoulder are rotator cuff pathology, osteoarthritis, and adhesive capsulitis.

Rotator cuff pathology is probably the best known shoulder joint injury, particularly in athletes involved in throwing sports, swimming or racquet
sports, and can vary from tendinitis to a full thickness tear. Aging is associated with an increase in rotator cuff tears, both partial and full thickness. Smaller tears are often successfully treated with arthroscopic
debridement, but this procedure is not as successful for full thickness tears thus leading to surgical repair of the tear. One study showed rates as high as 98 percent patient satisfaction after rotator cuff repair. The next logical question is what the most effective method of repair may be and as expected it depends on the type of tear and the patient (age, post-operative goals, health status, etc). The options are arthroscopic or open repair, single row or double row. WIth a partial tear the tear can be completed to a full tear then repair or it can be repaired in situ, not completing the tear before repair. The former technique is most common, but in situ repairs are showing a lot of promise with research reports of 94 to 98 per cent patient satisfaction. From a biomechanical perspective, double row repairs are stronger but not necessarily leading to an advantage with clinical outcomes.

Augmentation, another major mechanical emphasis in rotator cuff repair, involves using an extracellular matrix to help stimulate tendon healing. The tissue used for augmentation can be an autograft, allograft, xenograft, or synthetic material. Most recently, human dermal allograft shows the most promise with proven clinical results though new techniques for augmentation are being tested with platelet rich plasma and stem cells. Overall, it is important to differentiate age, desired level of sport, and type of sport before deciding on the treatment for rotator cuff pathology.

Osteoarthritis of the shoulder is not as common as the knee or hip, but it is
not uncommon and can be quite debilitating for older athletes. Treatment options include debridement, capsular release, microfracture, glenoid resurfacing, or total shoulder arthroplasty. Again it is important to
differentiate the athlete and desired goals in order to determine the best
treatment. For the older recreational athlete (65 and older), total shoulder
arthroplasty results in excellent long term survival rates and high level of
return to sport. For younger patients (under 50) almost 50 per cent reported unsatisfactory results in on research study after total shoulder arthroplasty and survival rates were much lower than in their older counterparts. For the younger but still mature athlete, the less invasive treatments are thus more common. Though the research is inconclusive as to which option is best for this population, biological glenoid resurfacing is the most recent promising treatment added to the list of less invasive options. The resurfacing can be achieved with an Achilles tendon allograft, lateral meniscus allograft, or dermal allograft.

Adhesive capsulitis is most commonly known as frozen shoudler and is charaterized by a loss of both active and passive range of motion at the glenohumeral joint. It is classified as primary idiopathic or secondary to
another pathologic process, and can often be associated with diabetes or thyroid disease. Treatment with nonoperative management is highly successful and should be the first option. Conservative treatment may include a steroid injection, physical therapy, or both. Operative treatment is considered with recalcitrant adhesive capsulitis or when conservative treatment fails as can be the case more often with younger patients or those with diabetes.

When considering treatment options for shoulder pathology it is essential to consider the patients demographics, particularly age, and desired level of activity or sport participation. While older athletes may have a more progressive or advanced injury process, often they have lower performance goals.

New Nontraditional Ways to Treat Shoulder Pain

In this article, Dr. Theodore Blaine from Yale University School of Medicine brings us up-to-date on the latest in biologic treatments for shoulder pain. In particular, Dr. Blaine’s area of expertise is the nontraditional treatment of shoulder arthritis. Nonsurgical, biologic treatment includes the use of medications, injections, cytokines, growth factors, platelet rich plasma, and stem cells. Here’s a brief summary of recent developments in this area.

Medications: Physicians continue to rely on the old standbys in this area (acetaminophen or Tylenol, nonsteroidal antiinflammatories, and corticosteroids). Studies show that acetaminophen remains a popular choice for relief of mild shoulder pain due to osteoarthritis. Acetaminophen combined with Tramadol (Ultram), a more narcotic-like (stronger pain reliever) is used for patients with severe pain.

Nonsteroidal antiinflammatory drugs (NSAIDs) offer better pain relief than acetaminophen but newer studies have shown some problems with rotator cuff tendon healing when taking these medications. NSAIDs seem to help most by improving patients’ ability to sleep and participate in physical therapy.

The use of oral (by mouth) steroids has fallen out of favor as studies show these medications provide only very short-term improvement in pain. Comparing groups of patients with shoulder pain taking steroids versus a placebo — 12 weeks later, the placebo group actually had better results.

Injections: Likewise, corticosteroid injections directly into a joint offer short-term pain relief, which in turn, gives patients better motion and function. There is some evidence that corticosteroids also reduce inflammation and may work better than nonsteroidal antiinflammatory drugs (NSAIDs) for some causes of shoulder pain (e.g., rotator cuff disease, bursitis).

Other types of injections include hyaluronate and botulinum toxin or BOTOX. Hyaluronate increases fluid within the joint and makes motion smoother and easier with less compression and shearing of the joint surfaces. Studies done by Dr. Blaine show that hyaluronate is a safe and effective treatment for shoulder osteoarthritis that has not responded to more traditional treatment with medications. The FDA has not yet approved hyaluronate for treatment of shoulder osteoarthritis.

BOTOX actually paralyzes muscles but also stops pain at the nerve endings. Although BOTOX has not been approved for use with shoulder pain, there appears to be little risk in using this injection therapy. This may be another nontraditional treatment technique for future use.

Cytokines: Cytokines are regulating molecules in the immune system and may assist in reducing inflammation. Cytokines may have a future role in providing a better solution to shoulder pain without the adverse effects of medications and injections. Areas of research right now are focused on the use of cytokines with patients who have bursitis and those with diabetes and rotator cuff disease.

Growth factors: Another possible way to encourage faster, better healing after rotator cuff surgery may be in the use of growth factors. Type I and Type III collagen fibers must be replaced and growth factors such as bone morphogenetic proteins (BMPs), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF), and transforming growth factor-B (TGF-B) may turn out to be the right tool for this. Studies are only in animal models at this time.

Platelet-Rich Plasma. Much has already been studied and written about regarding the use of growth factors found in platelet-rich plasma (PRP taken from the patient’s own blood). These growth factors may be able to aid in the repair of damaged soft tissues. Researchers are looking at various effects of PRP on rate of recurrent rotator cuff tears, tendon and muscle strength after treatment, effects on small versus large rotator cuff tears, and long-term results.

Stem Cells. Stem cells are the basic cells that can turn into any other kind of cell, including tendon. Utilizing stem cells to repair damaged tendons by the regeneration of tendon cells in rats and rabbits have shown mixed results. This is another biologic treatment tool that may yet be used but much more research is needed before the hows and whats of tendon regeneration via stem cells is ready for human use.

In summary, Dr. Blaine’s work of bringing more tools to the conservative side of treatment for shoulder pain from arthritis is important as more and more younger people are affected by this problem. Pain relief and improved function are the short-term goals.

Finding ways to enhance healing of the rotator cuff (especially after surgical repair) remain a challenge for future research studies. Biologic agents such as growth factors, stem cells, pharmacologic agents (or some combination of these) may have a central role in future treatments for shoulder pain.

Adhesive Capsulitis or Frozen Shoulder?

For many years, the terms adhesive capsulitis and frozen shoulder were used to describe the same condition. Patients experience shoulder pain and loss of shoulder motion. The problem comes on slowly over a period of time and seems to affect women more often than men (especially women between the ages of 40 and 60).

But experts recognize now that there are many different shoulder conditions that can present with these (or similar) symptoms. So the old term “frozen shoulder”, once used to describe any painful, stiff shoulder is now more refined. The term “adhesive capsulitis” may be a more accurate description for some patients.

As the name suggests, adhesive capsulitis affects the fibrous ligaments that surround the shoulder forming the joint capsule. This condition is referred to as primary adhesive capsulitis to differentiate it from “frozen shoulder” (secondary adhesive capsulitis).

Primary adhesive capsulitis is formed by inflammation, fibrosis, and contraction of the capsule with tiny adhesions holding the capsule to the bone. The normally loose parts of the joint capsule stick together. The result is pain and loss of motion from a mechanical (tissue) problem (adhesions causing tightness).

The condition referred to as a frozen shoulder usually doesn’t involve the capsule. Secondary adhesive capsulitis (or true frozen shoulder) might have some joint capsule changes but the shoulder stiffness is really coming from something outside the joint. Often, the short rotator muscles around the shoulder spasm. Sometimes, adhesions form inside the joint itself (rather than in the capsule).

Some of the conditions associated with secondary adhesive capsulitis (true frozen shoulder) include rotator cuff tears, biceps tendinitis, and arthritis. Any of these problems can seriously limit the shoulder’s ability to move, and causes the shoulder to “freeze.” Risk factors for adhesive capsulitis include: diabetes, thyroid problems, Dupuytren contracture, treatment for breast cancer, autoimmune diseases, and previous heart attack or stroke.

Current concepts in diagnosis and treatment of adhesive capsulitis were recently published. One of the most distinguishing characteristics of primary adhesive capsulitis is decreased shoulder external rotation when the arm is held next to the side. Active and passive shoulder motions will be equally limited when the capsule is involved. When these two types of motion differ, the problem may not be primary adhesive capsulitis.

Sometimes it is difficult to tell if motion is limited by capsular tightness versus the patient’s pain. That’s when it might be helpful to inject the joint with a numbing agent (e.g., lidocaine). Retesting the patient’s shoulder motion without the influence of pain can help differentiate between true primary adhesive capsulitis and some other cause of shoulder pain (and loss of motion). X-rays may be helpful in identifying these other causes of shoulder pain and blocked motion (e.g., osteoarthritis, dislocation, bone spurs, fractures, tumors).

Another useful diagnostic test to determine whether or not the joint capsule is involved is an arthrography. A dye is injected into the joint. Normally, the shoulder joint can hold about 15 milliliters of fluid. The person who has primary adhesive capsulitis will have a limited capacity because the portion of the capsule at the bottom (called the axillary fold) is contracted. No fluid can enter this normally pocket-like structure.

MRIs have limited ability to aid in the diagnosis of primary adhesive capsulitis. But an MRI can help rule out other causes and an MRI with contrast dye (arthrography) can show the presence of thickening in the joint capsule and ligaments. And when the MRI no longer shows the fat pad between the coracohumeral ligament and the coracoid process, the presence of primary adhesive capsulitis is confirmed.

Once the diagnosis has been made, then treatment can be prescribed. Physical therapy is the first line-of-treatment. It takes time to calm the pain signals and gain motion back, so a period of conservative care over several months is necessary. During this time, nonsteroidal antiinflammatory medications are often recommended for their short-term effects of providing pain relief. Steroid injections into the joint also provide a temporary decrease in pain and may aid in reducing inflammation in the early stages of the condition.

When conservative care fails to bring about the desired results, treatment may be expanded to include nerve blocks, hydrodilation (injecting a saline solution into the joint to expand/rupture the capsule), or manipulation under anesthesia (surgeon moves arm through full motion while patient is asleep).

When all else fails, surgery may be the last step. Arthroscopy is used to see inside the joint and release adhesions, scar tissue, and/or the capsule itself. Physical therapy after manipulation is required in order to maintain shoulder motion after manipulation or surgery.

Fractures of the Collar Bone in Teens Treated Without Surgery: What are the Results?

Children, adolescents (teenagers), and adults are all groups who sustain a clavicular fracture (clavicular refers to the collar bone). A bone break in the middle of the clavicle with displacement (separation of the fracture) can result in a shortened, misaligned clavicle. This particular deformity in adults has been shown to create abnormal biomechanical stresses throughout the entire upper quadrant (e.g., shoulder joint, shoulder blade, clavicle).

Surgery may be needed to realign the ends of the bone and reduce long-term disability. In fact, with adults, surgery does produce better results and greater patient satisfaction compared with conservative (nonoperative) care. And studies have confirmed that without surgical correction, many patients with displaced clavicle fractures end up with a nonunion, displaced, shortened bone.

The question naturally arises: what happens in teens with this type of injury who are treated nonoperatively? Can they regain normal motion and strength? Can those who are athletes return to a level of full pre-injury sports participation? The results of this study suggest “yes” to all of those questions.

There were sixteen adolescents enrolled in the study in a 4:1 ratio of males to females (i.e., 12 males and 4 females). The majority of teens (13 of the 16) broke the clavicle on the nondominant side.

Treatment was with the arm on the affected side in a sling until X-rays showed healing had occurred. Measurements were taken before and after treatment of shoulder motion, length of the clavicle (fractured bone compared to the other side), and strength (isometric muscle testing). Each of these measurements was compared to the normal side.

There were very few differences after treatment between the fractured side and the uninvolved arm. Slight differences were noted in external rotation strength and abduction endurance. Despite changes in the length (longer or shorter) of the clavicle on the fractured side, there was a 100 per cent rate of union (healing of the two fractured ends of the clavicle).

Only one of the 16 patients was unhappy with the results and that was because that particular person still had shoulder pain. And everyone returned to their full activity level, even those who were involved in sports.

The results of this study support Mercer Rang’s axiom, If the two ends of the clavicle are in the same room, they will heal. Reliable healing with few long-term symptoms is possible and even probable because the bone will remodel successfully in this age group. There is a minimal loss of strength due to biomechanical changes in clavicular length. This has the potential to put stress on the joints of the shoulder and decrease the force generated by the muscles for strength. Even so, these teens were still able to function fully in all daily and sports activities.

If surgery can be avoided with conservative care only, it may be possible to eliminate complications such as numbness from the incision and/or infection. Likewise, with conservative care, there is no need for fixation with metal plates or other hardware that may need to be removed later in a second surgery. This study confirmed that the nonoperative approach can be successful with midshaft clavicle fractures in teens.

Rate of Return to Elite Baseball Pitching Following Shoulder Surgery

There are many different reasons why elite baseball pitchers may need shoulder surgery. But the biggest question is always, How long will it be before I can go back to pitching? Some answers can be found in this systematic review.

Surgeons from the Division of Sports Medicine (Department of Orthopedic Surgery) at Rush Medical College in Chicago, Illinois searched several electronic data sources for studies that might address this question. They found six that qualified with a total of 287 elite pitchers.

All were men, most were professional athletes, and all had reparative or reconstructive shoulder surgery. Almost all of the pitchers (99 per cent) injured their dominant (pitching) arm. And many had more than one shoulder injury requiring surgical correction. Injuries included rotator cuff tears, impingement, joint laxity, joint degeneration, labral tears, and internal impingement.

The authors were interested in establishing the rate of return to sports participation among these elite baseball pitchers after surgery. They found that 68 per cent of the players were able to get back into action (pitching competitively) approximately 12 months after surgery.

Some players were able to return to pitching within nine months after the surgery. Others were not ready for a year and a half (18 months). Very few actually made it back to sports participation the same year they had the surgery. This was especially true for those who had rotator cuff or labral surgery.

If 68 per cent were able to return to pitching, what happened to the other pitchers? Twenty-two per cent (22%) never made it back and ended up retiring from professional baseball. Those who returned to pitching reported some noticeable differences from before their injuries. For example, they pitched far fewer innings post-operatively compared with pre-injury. Certainly, the successful group was able to pitch more than they could after the injury or just prior to surgery.

What was important to the players was pitch accuracy, speed, and endurance. Follow-up over the next three and a half years showed a gradual, continued improvement in all areas of performance (e.g., strikeouts, walks, hits per inning pitched). Complaints reported by pitchers included early fatigue (compared to pre-injury status) and a sense of loss over pitch control. Measurements taken did show a slight decline in maximum pitch velocity (from 94.2 miles per hour to 90.1 miles per hour).

The authors were unable to show comparisons based on the different types of shoulder surgery. The best they could do was suggest that there isn’t a significant difference in results or outcomes between the different problems operated on. There were just too many different tools used to measure performance to compare directly.

In conclusion, overhead throwing (i.e., pitching) requires a fine balance between movement (mobility) and stability. Obviously, not everyone who wants to pitch professionally makes it to the elite level required for professional sports. The years of training and repetitive number of pitches to get to that level can take a toll on the athlete.

With only slightly more than two-thirds of the pitchers returning to play following shoulder surgery (and very few during the same season), every effort to rehab with a conservative approach is advised. Overhead throwing athletes must be advised that surgery may not result in a full return-to-play. And they should be told that if they are able to return to pitching, they may not reach pre-injury levels of pitching.

What’s the Mechanism Behind Shoulder Replacement Loosening?

Total shoulder replacement for severe joint osteoarthritis has come a long way since its first use. But it isn’t perfect yet. Ten to 15 per cent of patients receiving this implant later develop loosening of the glenoid component (socket side of the implant).

The reason for glenoid component loosening is the focus of this study from the Cleveland Clinic in Ohio. The type of implant used was a polyethylene (plastic) press-fit (not glued in but pressed against the bone so that more bone would fill in around it) design. A peg in the center of the socket implant helps hold it in place until bone in-fill takes place.

Loosening is observed on X-rays as osteolysis (bone loss as the body resorbs bone cells). What causes this? Is it more likely to develop the more time goes by after shoulder replacement? Is it linked with the shape of the glenoid side of the shoulder before surgery? For example, retroversion (tipped back) position of the socket may contribute to the osteoarthritic degenerative changes in the first place and may also be linked with osteolysis leading to loosening.

To find out, 66 patients who received the DePuy Anchor Peg Glenoid Component were followed up. All surgeries to implant the shoulder replacement were done by one surgeon. When there was too much retroversion, the surgeon did his best to correct the problem. He did this by shaving or cutting away excess bone along the front of the glenoid. The goal was to create a glenoid (socket) that was perpendicular to the scapula (body of the shoulder blade where the glenoid is located).

In some cases, the surgeon was unable to obtain a perfect fit with complete correction. To get complete correction of glenoid retroversion would require taking off too much bone. It was better to remove as much bone as possible to re-align the glenoid but without taking so much that it was no longer possible to insert the glenoid component.

To measure results, patients completed a health survey and answered questions about satisfaction after surgery. X-rays were taken before and after surgery and compared. About half of the patients had CT scans ordered when X-rays were not enough to fully see the glenoid. These imaging studies were repeated postoperatively and made it possible for the surgeon to evaluate the bone, assess alignment (e.g., retroversion, accuracy of glenoid component to scapula interface), and look for any signs of implant loosening around the central peg.

It turned out that pre- and postoperative glenoid retroversion was the main factor in osteolysis and peg loosening. More than 15 degrees of tilt still remaining after surgery contributed to early loosening. It is believed (but has not been conclusively proven yet) that the retroversion causes increased load on the humeral head.

The surgeon concluded by suggesting that whenever possible, glenoid retroversion should be corrected to within 15 degrees before placing the implant into the shoulder. This also means that many things must be taken into account when preparing for shoulder replacement.

The surgeon is advised to use advanced imaging studies to look for pathology (i.e., problems with alignment, presence of bone deficiency). Both X-rays and CT scans should be taken pre-operatively (CT scans before surgery were not standard practice at the time of this study). And special care must be taken when selecting the implant used in order to accommodate for pathology and alignment problems observed preoperatively.

What To Do When the Patient Isn’t Right for a Shoulder Replacement

In this article, surgeons from the Cleveland Shoulder Institute in Ohio offer their best advice about how to treat three groups of patients who might not be right for a shoulder replacement but need treatment just the same.

The diagnosis of shoulder osteoarthritis usually leads to successful results (less pain, better motion and function) with a shoulder replacement. But there are certain patients for whom studies show conventional shoulder replacement doesn’t always result in good outcomes.

In particular, young patients (younger than 60 years old) with osteoarthritis, adults with posttraumatic arthritis, and individuals with specific lesions (damage, defects) to the head of the humerus (upper arm bone) fall into this category.

The biggest concerns are for how long the implant will last in someone who may live another 20 years (or more) and the increased likelihood of revision (second) surgery. The most common problem that develops in the younger age group is loosening of the implant.

If the traditional shoulder replacement won’t work for these patients, then what else can be done for them? The authors discuss two separate categories of potential treatment: types of arthroplasty (surgical repair of the joint) and nonarthroplasty (but still surgical) alternatives.

Arthroplasty options include: shoulder resurfacing, using a short-stem humeral implant, and glenoid “reaming” without an implant (called ream and run). Humeral head resurfacing has been around for 25 years but the short-stem humeral implant is fairly new technology. “Ream and run” involves smoothing the glenoid (socket side) of the shoulder joint and restoring the round shape as much as possible.

Nonarthroplasty treatment suggested included debridement with capsular release, microfracture, autologous chondrocyte implantation, and osteochondral allograft resurfacing. In the future, long-term results of these alternative approaches will aid shoulder surgeons in determining which technique is best for each patient. For now, evidence is limited but outcomes are promising.

Here are a few more details about these alternative options to traditional shoulder replacement in young patients with osteoarthritis. The main advantage to shoulder resurfacing and a short-stem humeral component is that these techniques preserve (save) bone. Only the damaged portion of the shoulder is replaced (not the whole shoulder). Bone spurs (called osteophytes are shaved away. The normal anatomy can be restored with less bone removal. Bone preservation makes it possible to delay (but not prevent) total shoulder replacement if and when further surgery is needed.

There is also a newer approach to resurfacing the shoulder joint and that’s called biologic glenoid resurfacing. In this case, the socket side of the joint (rather than the head of the humerus) is resurfaced. This can be done with a variety of different soft tissues to smooth the joint surface. The technique is called interpositional arthroplasty and uses human skin matrix, human tendon graft from a donor, the patient’s own connective tissue from the fascia lata along the outside of the thigh, or pig graft material.

On the nonarthroplasty side of things, the focus has been on trying to repair the damaged cartilage. The goal is to provide relief from pain and improve function. This is done by removing torn, damaged, or loose pieces of joint cartilage and smoothing or filling remaining holes, lesions, or “defects.”

Microfracture aids in repairing the joint surface by causing bleeding into the joint. The body creates new fibrous cartilage in the area where tiny holes have been drilled through the joint surface into the bone marrow. Alternatively, the surgeon can use cartilage cells (either harvested from the patient or from a donor) to fill in and then smooth over defects. Using the patient’s own chondrocytes (cartilage cells) is ideal because there’s a greater chance for cells to survive the transplantation process. But patient grafts also come with potential for problems at the donor site.

In summary, traditional shoulder replacement doesn’t always provide the hoped-for results. And it’s difficult to predict who will have a good result and who won’t. Therefore, alternative treatments have been proposed, used, studied, and reported on. Shoulder surgeons will find the information in this review article on the many alternative operative techniques to treat shoulder osteoarthritis in young patients of interest.