News Category: Shoulder

Many older adults return to sports or recreational activities after a hip or knee replacement. Why not after a total shoulder replacement (TSH)? More and more adults age 65 and older are enjoying golf, swimming, tennis, and softball. A painful shoulder that’s limited in motion can interfere with these activities.

This is only the second study reporting on patient sports involvement after shoulder replacement. Over a 10-year period of time, 75 active patients with 86 shoulder replacements were followed for at least two years. Sports participation and level of competition were assessed. Frequency of activity, time it took to get back into action, and level of ability were all measured.

Most of the patients had some type of arthritis — osteoarthritis, inflammatory arthritis, or posttraumatic arthritis. A wide range of data was collected and compared for each patient. Age, reason for surgery, hand dominance, type of procedure, medication use, and any other health problems were collected and categorized. Patients were asked to report any further surgery they may have had on the shoulder with the replacement.

The authors presented a table of type of activities and number of patients involved in each one. They also provided a bar graph with rate of return to sports after shoulder replacement. More than half the patients participated in more than one activity. Most were unable to join in any sports events just before surgery. This was due to pain, loss of motion, and decreased function.

Activities ranged from swimming (most common activity) to handball (only one patient in this category). Golf, tennis, downhill skiing, weight lifting, fishing, softball, and bowling were other commonly reported activities for this group of patients. Less often, hunting, ballroom dancing, horseback riding, kayaking, and basketball were listed. A few patients were involved in bodybuilding, aerobics, wrestling, and sailing.

The rate of return to each activity was as low as 20 per cent for softball and as high as 92 per cent for fishing. Many of the more common activities had a 75 to 86 per cent return rate.

On average, it took three to four months for patients to return to a sporting activity on a part-time basis. Full return to sports took another three months’ time. About 20 per cent did not resume any kind of sports or recreational activity. Other health problems such as high blood pressure, asthma, and diabetes were factors in this decision.

The authors concluded that active patients don’t have to put aside sports and recreational involvement after a shoulder replacement. Repetitive motion such as swimming isn’t a problem. Many of the older athletes even reported improved ability after the surgery. Patients were less likely to resume sports requiring full range of motion with load such as softball or weight lifting.

Sometimes tears of the rotator cuff tendon (RCT) are so severe, they can’t be repaired. Trying to bring the two torn ends together puts too much pressure on the tissue.
In this study, researchers from Seoul, Korea report on a way to bridge the gap and obtain complete healing of the RCT. They used the biceps tendon as an interposition repair.

The surgery was done on 31 shoulders with massive, irreparable RCT tears. The same surgeon performed all the surgeries. Half the group had an open procedure with a five-centimeter (two inches) incision. The deltoid muscle was split in half in the process. The other half had arthroscopic surgery. Small puncture holes were made for the scope to pass through the skin into the joint. The deltoid muscle was left intact.

The long head of the biceps tendon was cut close to its attachment at the glenoid labrum. The labrum is a dense ring of fibrous cartilage. It goes around the rim of the acetabulum (shoulder socket) to increase the depth and stability of the shoulder joint.

The surgeon used a suture retriever to reach in and pull the ends of the RCT back together as closely as possible. The biceps tendon was then used as a graft. It was placed between the two torn ends of the RCT and stitched in place (interposition repair).

This bundle of soft tissue was then attached to the bone in a procedure called a tenodesis (tendon-to-bone attachment). Braided sutures and suture anchors were used to hold everything together while it healed.

Everyone in both groups had six-to-eight weeks of rehab. Passive motion was allowed right from the start. Active motion was allowed when the patient had full passive range-of-motion (or six weeks after the surgery). Muscle strengthening exercises were slowly added at six weeks post-op. Any stressful activities or positions weren’t allowed for the first six months.

Results were measured using pain, range-of-motion, and strength. Several tools such as the University of California at Los Angeles (UCLA) score, the Simple shoulder Test (SST), and the Constant Score were used to measure function. A myometer was used to measure muscle strength.

The results showed reduced pain at rest and during exercise in both groups. Improvements in motion and strength were also observed in both groups. Overall, the clinical results between the open and arthroscopic groups were the same.

Magnetic resonance imaging (MRI) was used to assess post-operative tendon healing. The radiologist knew the patients had surgery for a torn RCT. But he did not know the size or location of the repaired RCT tear. There was complete healing in 64 per cent of the arthroscopic group. The remaining patients in the arthroscopic group had partial or complete retears. There was only one case of retear in the open group.

The authors report the 64 per cent rate of success is much better than rates reported in other studies using other repair methods. The advantage of the biceps interposition repair is that the graft serves as an internal splint while healing occurs.

By performing a tenodesis (tendon-to-bone attachment), tension is taken off the repaired (healing) site. At the same time, there is enough tendon-to-bone contact to restore normal biomechanics. This may help prevent re-rupture and a failed surgery. The patient experiences pain relief and does not have any obvious cosmetic deformity.

In summary, the biceps interposition graft for massive rotator cuff tears had good results. The study was not conducted with comparison groups, so it was not possible to say the interposition technique was superior to other methods of repair. More research is needed to identify the best way to assure repair integrity.

Over 100 cases of acute distal clavicular osteolysis (ADCO) in weight lifters have been reported in the medical literature in the last 25 years. Sometimes this problem is referred to as weightlifter’s shoulder. It is an overuse phenomenon that causes tiny fractures along the end of the clavicle (collar bone). A breakdown of bone (osteolysis) occurs.

In this report, the authors review and summarize what is known about this problem. Although male weight lifters are affected most often, there have been reports of ADCO in a judo player, deliveryman, handball player, and some soldiers. Female bodybuilders are also at increased risk for this ADCO.

There may be a history of an acute injury of the AC joint. But the condition can occur without any known trauma. In most cases, there is repetitive stress to the affected upper extremity. Weight training, intensive lifting, and operating an air hammer are examples of the activities leading to ADCO.

There is evidence that the body tries to heal itself but the bone dissolves or is resorbed by the body instead. A network of blood vessels form in the area during the attempted healing process. Chronic inflammation with scar tissue called fibrosis is commonly found when tissue from the area is examined under a microscope.

The synovial lining of the joint starts to overproduce itself. Invasion of the underlying bone begins. Degenerative joint disease occurs as an end-result of the pathologic process.

Aching pain along the front of the shoulder at the acromioclavicular (AC) joint is the first symptom. Moving the arm across the body hurts. It gets worse with weight training involving the upper extremities (arms). Activities such as push-ups, bench presses, dips on the parallel bars, and throwing motions make the symptoms worse.

The diagnosis is made using X-rays, scintigraphy (bone scan), and steroid injection. CT-guided injection is actually a diagnostic tool and a treatment. Pain relief with steroid injection into the AC joint confirms that the pain is coming from the AC joint.

Treatment begins with conservative (nonoperative) care. This may include rest and/or changes in weight-training activities and techniques. The authors provide specific and detailed advice about changes that can be made in training.

Ice massage and nonsteroidal antiinflammatory drugs (NSAIDs) are used after all exercise sessions. Athletes must be observed carefully as many of them will work through the pain and not really modify their program. Surgery may be needed for those athletes who do not improve with conservative care or who are unwilling to change the training or performance routine.

The surgeon removes the end of the clavicle. This is called a distal clavicle resection. The procedure can be done with an open incision or through tiny puncture holes with an arthroscope.

Repair of any torn soft tissue in the area is done at the same time. Some surgeons transfer the coracoacromial ligament over the end of the bone that has been cut. This helps stabilize the joint. Other surgical techniques (both open and arthroscopic, direct and indirect) are discussed in detail.

Training can begin the first week after surgery (sometimes in the first few days). Pain is relieved in a majority of patients. It can take about four to eight weeks for the pain to subside completely. It is possible to return to competitive lifting sports at a preinjury level or better within a week or two. Likewise, there are reports of manual laborers returning to full work duties. The turn around time is very short.

Patients should be warned that there can be some problems. Abnormal motion of the AC joint can lead to a poor result. In such cases, pain is not relieved. There can be muscle injury, prolonged bleeding, infection, and fracture of the clavicle during the procedure. Smokers are at greater risk of poor wound healing and failed surgery.

Athletes involved in overhead throwing sports are at risk for rotator cuff tears. Most of these players are young adults. But there are a fair number of middle-aged and older adults who still play competitively in recreational or amateur overhead-throwing sports. They are the subject of this study on arthroscopic rotator cuff repairs.

Athletes (men and women) in the 46 to 69 year age range were included in this study. All patients had arthroscopic surgery to repair a supraspinatus tear. The supraspinatus is one of the four muscles/tendons that make up the rotator cuff in the shoulder. Everyone was followed for at least two years.

Results for the group of athletes were compared to a similar group of adults who were not invovled in sports. Measures of outcomes included MRI results showing the structural integrity of the repair, pain, motion, and strength. Function and retear rate were also measured and compared. Evaluation of sporting activity for both groups was rated by the athlete three different times: before injury, before surgery, after surgery.

Everyone followed the same rehab program after surgery. Everyone improved in pain, motion, strength, and endurance. Retear rates were the same for both groups (about 25 per cent). At the end of two years, all athletes were back in action and at (or close to) their preinjury level of participation. Those who injured their dominant arm had a better result after the surgery.

The authors conclude that arthroscopic repair of rotator cuff tears can have good to excellent results in older athletes. Women tend to have more pain than men afterwards. But they regain endurance and joint range of motion faster and better.

Rotator cuff tears can be difficult to treat. When surgery is delayed, severe pain can cause the shoulder capsule to tighten up. The result is a stiff shoulder with loss of motion.

What’s the best way to treat this? Should the shoulder be manipulated surgically first? Then repaired later? Or is it better to do both the manipulation and the repair at the same time? In this study from Korea, results of surgery are compared for patients with and without shoulder stiffness.

Everyone had an arthroscopic rotator cuff repair with the same surgeon. Pain, motion, and strength were the measures of outcome. Results were compared at three and six weeks, three and six months, and one year post-operatively. It was expected that the group with the stiff shoulders would have a slower recovery and poorer clinical results after the operation.

Patients in both groups attended the same clinic for rehab. They all followed the same rehab program in the clinic and at home. There was no difference in pain levels between the two groups. Both groups had significant pain reduction after surgery.

Likewise, function returned equally for patients in both groups. But the manipulation group had a slower recovery. It took much longer (up to one full year) to regain shoulder flexion in particular. Other motions were slower to return in the manipulation group but only for the first six weeks.

The authors concluded that rotator cuff tears with stiffness can be treated all at the same time. A single operation can save money and reduce the overall time the patient’s life is disrupted. Patients have a good result but should expect a slower recovery.

Shoulder arthroplasties, or replacements are not unusual, but regular replacements are not the right answer for many people. Some need what is called a reverse shoulder arthroplasty. This is mostly used for people who have injuries of the rotator cuff due to arthritis.

Reverse replacements put the ball of the joint just off the shoulder blade with the socket off the upper arm rather than the usual ball at the top of the bone and the socket on the shoulder blade.

Early designs of reverse replacements had mechanical failures. The authors of this study examined a technique that used locking screws on the baseplate and an adjusted center of rotation for the shoulder. They enrolled into their study 112 patients with 114 shoulders that needed repair. By the end of the study, they had 94 patients with 96 treated shoulders for evaluation. The average age of the patients was 72 years and the majority of patients (63) were women. Assessment before surgery included computed tomography scans (CT scans) and a videotape of the patients’ movements before surgery, using the shoulder moving forward, backward, and up and down. The patients were also asked to score their pain using the American Shoulder and Elbow Surgeons Score (ASES), the Simple shoulder test (SST), as well as reports of their overall satisfaction with their shoulder.

After surgery, the patients’ shoulders were immobilized for six weeks but they did perform pendulum exercises every day. After six weeks, the patients were allowed to use their shoulder and they began gradually use their arm for every day activities. They were only allowed to start strengthening exercises at three months after their surgery.

Upon reviewing the results, the researchers found that the average total ASES score improved from 30/100 before the surgery to 77.6 after. The average individual ASES scores rose from 15 before surgery to 41.6 after surgery. The average SST scores rose from 1.8/10 before surgery to 6.8 after.

When examining the patients’ range of motion, the researchers found that there were improvements in all angles and directions from before surgery and after.

There were some complications after surgery. Six patients experienced nine complications total. One patient fell three months after surgery and fractured the shoulder, but this was treated with immobilization. Another patient fell 27 months after surgery and needed surgery to repair the shoulder. One patient developed a severe infection in the shoulder, and three patients developed dislocations without trauma.

Eighteen patients were not followed up because they did not respond to follow-up requests.

The authors write that this procedure increases success with the patient outcome and limits the amount of mechanical failure.

Researchers are trying to find ways to detect full-thickness tears of the rotator cuff without the expense and invasiveness of an arthroscopic exam. To do this, they are comparing the results of clinical tests with ultrasound results. The advantage of the ultrasound is that both shoulders can be viewed. This gives a side-to-side comparison that isn’t possible with standard arthroscopy.

In this study, the accuracy of three specific tests called the lag signs are studied. These include the external rotation lag sign, the drop sign, and the internal rotation lag sign.

Each procedure specifically tests one or more of the four tendons of the rotator cuff. The authors described each test in detail. All three tests were performed on 46 painful shoulders in 37 patients. Right after the clinical testing, diagnostic ultrasound tests were done on both sides.

The results showed that there isn’t one single test that can accurately diagnose a rotator cuff tear. The rotator cuff tendons are not easily isolated. They come together closely and insert around the shoulder. A negative test doesn’t necessarily mean the patient doesn’t have a full-thickness tear. And a positive test result doesn’t always mean there is a full-thickness tear.

The bottom-line is that clinical lag tests can’t be relied upon. This is especially true in the older groups who often have full-thickness rotator cuff tears without any symptoms. Many people with painless tears have normal function. It’s only when pain enters the picture that the condition becomes a problem.

Advanced imaging using either ultrasound or arthroscopy is still the most reliable diagnostic methods. Ultrasound has the added advantage over arthroscopy of providing comparisons from side to side.

Many painful shoulder problems can be managed quite well with a steroid injection. When injected into the right spot, cortisone can reduce inflammation and relieve painful symptoms. The end-result is improved range of motion, strength, and function.

In this article, the authors present a 16-step exam used to guide the diagnosis of shoulder pain. An accurate diagnosis is essential for successful steroid injection. The 16-steps include visual inspection and physical examination of the shoulder.

Physical exam includes specific shoulder tests, active and passive range of motion, and muscle strength testing. The area of focus for strength testing is the rotator cuff (four tendons that envelope the entire shoulder joint). X-rays are always advised in order to improve the accuracy of the injection(s).

What to look for and how to interpret the shoulder tests is presented. The sensitivity and specificity of each test is reported. The authors remind us that previous studies have showed that combining certain shoulder tests can dramatically improve the accuracy of the tests.

For example, combining the painful arc sign with the drop-arm sign and the infraspinatus test is the best predictor of full-thickness rotator cuff tears. And impingement syndrome is tested for by using the painful arc sign, Hawkins-Kennedy impingement sign, and the infraspinatus muscle test.

Special tests for specific conditions such as tendinitis, arthritis, and rotator cuff tears are reviewed. Likewise, tests for strains, sprains, trigger points, and frozen shoulder are also included.

By using the 16-item checklist, physicians can narrow down the diagnosis and target the tissue that can benefit from a corticosteroid injection. Once the injection has been completed, the numbing agent will mask the pain. Then the examiner can sort out which parts of the shoulder joint are affected most. Improving accuracy is the key to limiting steroid injections while increasing effectiveness.

New statistics are available on the rate of return to sport (RTS) for baseball players. The focus of this study was professional baseball players, especially pitchers. Players were included from the major league, class AAA minor league, and class AA minor league. Forty-four (44) players in one of these three groups had elbow or shoulder surgery.

The outcomes were tabulated with the following results:

In this study, Canadian orthopedic surgeons report on the results of two different surgical techniques for tears of the rotator cuff. Patients who were included all had a full-thickness tear (complete rupture). The two procedures compared were:

More and more orthopedic surgeons are finding that treatment depends on an accurate diagnosis of the problem. In this review of superior labral anterior posterior (SLAP) injuries of the shoulder, the accuracy of clinical tests is reported. The authors tell us which tests to use and what the test results mean.

SLAP injuries refer to a tear along the top (front and back) of the labrum. The labrum is a rim of fibrous cartilage around the shoulder socket. It provides depth and stability to the socket.

Seventeen studies over a 10-year period of time were included in this systematic review. The authors compared the sensitivity, specificity, and likelihood ratios for dozens of tests used in the evaluation of shoulder pain and problems.

Sensitivity tells us how good the test is in identifying patients with a SLAP injury. Specificity tells us how good the test is in identifying patients who do not have a SLAP injury. Both of these measurements are used to calculate the likelihood ratios.

These ratios refer to how much more likely (or unlikely) a positive (or negative) test is to be found in patients with the condition compared to people without the problem. These ratios are very useful when looking at the diagnostic accuracy of clinical tests.

After carefully assessing sensitivity, specificity, and ratios for all these tests, there wasn’t one that was good enough to detect the presence (or absence) of a SLAP tear. Tests with the highest levels of accuracy included active compression, compression rotation, biceps load (two separate tests), and the crank test.

More studies are needed to identify which test is best for different types of SLAP lesions. Some tests may be better than others for specific types of SLAP injuries (e.g., falling on an outstretched hand versus overhead throwing injuries). And it may turn out that a combination of tests works best for one injury over another.

For now, it is important that examiners agree on what is a positive or negative result for each test. This will help improve the validity and accuracy of tests.

Surgical release of the shoulder capsule is one treatment option used for frozen shoulder. The capsule is formed by ligaments that surround the shoulder. The procedure is done arthroscopically. This allows the surgeon to see inside the joint. Capsular release under these conditions reduces the danger of further damage to the joint.

In this study, surgeons perform a capsular release including part of the subscapularis muscle. The subscapularis is one of the four muscles that form the rotator cuff. It helps the shoulder rotate internally. The subscapularis muscle inserts into the front of the shoulder capsule. It helps stabilize the shoulder and prevents anterior (forward) dislocation.

There is some concern that release of the intra-articular part of the subscapularis would affect shoulder rotation. The surgeons only released the subscapularis if they could not externally (outwardly) rotate the frozen shoulder to 50 degrees.

Range of motion, strength, and function were measured comparing the nonoperated shoulder to the operated side. Motion was improved in all directions. Pain was reduced and function improved. Strength testing showed no difference for internal or external rotation strength between the operated and the nonoperated shoulders.

The authors conclude that release of the subscapularis tendon for severe frozen shoulder is safe and effective. Motion is restored without compromising strength. Patients were satisfied with the results.

This study does not answer the question whether capsular release with subscapularis release is more effective than without the tendon release. Further studies are needed to compare these two approaches.

This is the first study to directly compare muscle strength after open versus arthroscopic surgery for recurrent shoulder dislocation. Other studies have reported on muscle strength after open surgery OR after arthroscopic surgery — but never comparing the two.

Results from other studies have been varied. Some showed a loss of strength, others didn’t. Strength deficits were observed in both internal and external shoulder rotation after arthroscopic surgical stabilization.

The subscapularis muscle of the rotator cuff is split in two during the open procedure. It has always been suspected that strength would be disrupted more after this approach. In this study, there were changes in strength for both internal and external rotation for both groups. The biggest factor linked to changes in strength was arm dominance.

The researchers tested strength for the surgical side as well as the uninvolved (nonoperative) arm. Strength was tested at different speeds and angles to represent functional tasks. Testing was performed at baseline (before surgery) and one year after surgery.

The results showed that the nonoperative arm was always stronger than the surgical side. This was true even when the dominant arm was operated on. But in general, the greatest loss of strength occurred in the nondominant arm no matter which kind of surgery was done.

The amount of strength deficit was different from patient to patient and varied as much as 20 per cent from one patient to another. Post-operative external rotation was weaker than internal rotation for both groups.

Overall, there was no significant difference in muscle strength one year after open or arthroscopic surgery to stabilize the shoulder. Both groups had loss of strength in rotational motions. Splitting the subscapularis during the open procedure did not seem to make a difference in long-term strength outcomes.

The loss of strength after this procedure suggests a need to review rehab protocols. It may be necessary to revise the rehab approach after shoulder stabilization surgery. Regaining rotational strength is an important goal that must be better addressed.

In this case report, a physical therapist, orthopedic surgeon, and osteopathic physician work together to present the treatment of a young, active patient with severe shoulder arthritis.

The patient was a 28-year-old man who had first dislocated his shoulder at age 16 while playing football. After a shoulder dislocation that did not respond to conservative care, multiple surgical procedures were needed. The patient continued playing sports and later worked as a manual laborer. He had recurrent shoulder dislocations and developed osteoarthritis.

Various surgical procedures were done over the years. After the first injury, an arthroscopic repair of the labrum was performed. The labrum is a dense ring of fibrocartilage around the shoulder socket. It provides depth and stability for the shoulder.

During a second arthroscopic surgery, the surgeon removed a loose fragment in the joint and repaired the labrum again. At that time, there was a severely stretched ligament (part of the shoulder capsule). The surgeon tightened the ligament along the anterior shoulder capsule. There were also some early signs of joint degeneration.

Later, a work injury resulted in another shoulder dislocation. Four more surgical procedures were needed over the next few years. Pain and loss of function led to the decision to try an interpositional arthroplasty. In this operation, meniscal tissue from a donor knee was used to resurface the patient’s shoulder joint. The head of the humerus was replaced with an artificial implant. The replacement of only one side of a joint is called a hemiarthroplasty.

Rehab was planned and carried out. Special consideration was given to the fact that the patient had a long history of shoulder instability and joint degeneration before the joint resurfacing operation. Release and repair of the subscapularis muscle was another important factor to consider.

The authors provided a detailed description of the rehab process and results. Immediate care with a sling was followed by physical therapy (PT). PT started at two weeks after surgery and continued for 12 weeks (three times a week). The authors gave careful thought to the when, how, and why of each part of the rehab program.

Short-term results included greatly reduced shoulder pain, increased motion, and improved function. The shoulder was stable enough to allow the patient to return to work. This was a successful treatment of a young, active adult with shoulder arthritis and instability. Using a partial shoulder replacement and biologic grafting was a good short-term option. Further follow-up is needed to determine the long-term outcomes.

A group of orthopedic surgeons from Sweden started a study 25 years ago. They wanted to assess the results of nonoperative treatment for anterior shoulder dislocations. The patients in their study were all 40 years old or younger.

Most (80 per cent) were men. They all had their first anterior shoulder dislocation in 1978 or 1979. More than half were involved in a sports activity when the dislocation occurred.

Patients were divided into two nonoperative groups. The first group was immobilized with a bandage that held the arm against the front of the body. They kept the arm still in that position for at least three to four weeks.

The second group was placed in a sling that could be removed whenever they were comfortable enough to do so. Some of the patients in this group wore the sling a few days. Others wore it a week, two weeks, or three weeks.

Everyone in both groups was assessed after the shoulder dislocation using X-rays, an interview with the doctor, and a physical exam. The patients filled out a questionnaire that was used to measure their shoulder function. Level of athletic activity was also recorded. Follow-up occurred at two, five, ten, and 25 years.

The authors report that immobilization treatment was not linked with recurrent shoulder dislocations. Patients between the ages of 12 and 22 years were more likely to develop a second shoulder dislocation. The reason for this was not clear. There was no significant difference based on gender or activity levels.

According to the results of this study, immobilizing (or not immobilizing) a dislocated shoulder doesn’t change the final outcome. There were no differences between the two treatment groups over time. First-time dislocations can be treated nonoperatively. Most stabilize on their own without surgical intervention.

Orthopedic surgeons are making rotator cuff repairs using arthroscopic techniques. Studies show that this method produces results similar to the standard open incision or mini-open repairs.

But the failure rate is much higher for arthroscopic shoulder repairs compared to mini-open and open repairs. And other studies have shown that repair failure occurs most often during the first two months.

In this study, sutures used to repair a torn rotator cuff are compared using three different techniques. The hope was to understand immediate repair strength as it relates to early failures. The goal is to find ways to reduce failures caused by suture failure.

Thirty human shoulders from cadavers were used in this study. All shoulders were free of any rotator cuff tears. The cadavers were matched as closely as possible for age and bone quality. A defect in the supraspinatus tendon of the rotator cuff was then surgically created and repaired.

Repair techniques included Mason-Allen sutures, the knotless anchor method, and the corkscrew suture anchor method. These are all double-row suture techniques. The medial row was always done with two suture anchors. The lateral row used one of the techniques just mentioned. The authors describe the formation and placement of each type of suture.

Cyclic load was then applied to the repairs until 5,000 cycles or failure occurred (whichever came first). Five thousand cycles is equal to 50 loading cycles during daily activities for the first 12 weeks after surgery. This type of biomechanical testing is common in studies of this kind.

Here’s what the researchers found:

Shoulder problems are common among overhead throwing athletes. Anterior instability along the front of the shoulder occurs as a result of repetitive microtrauma. Posterior instability (along the back of the shoulder) is much less common. This condition occurs with repetitive microtrauma during the late cocking and follow-through phases of overhead throwing.

There aren’t very many reports on the treatment of posterior shoulder instability. In this study, arthroscopic repair of the posterior capsule and labrum is compared for overhead-throwing athletes compared with nonthrowers. Results were measured based on stability, motion, strength, pain and function.

All patients had unidirectional posterior instability. This means the instability was in one direction only rather than being multidirectional (present in more than one direction). The patients were all athletes but not all were throwing athletes. Differences were compared based on this one factor (throwers versus nonthrowers).

Surgery was done to stabilize the shoulders. Arthroscopic exam was performed to assess tissue damage and the location, direction, and amount of instability. Fraying or tears of the labrum (capsular rim) and the quality of the soft tissues around the shoulder were observed. Surgery to repair the damage was then done arthroscopically. The authors described the various types of surgical procedures used.

The authors report no differences between the two groups. Patients in both groups showed a big improvement in all areas tested. Throwing athletes did not always return to their preinjury level of sports participation. Overall, the results were good to excellent with only one case of poor results (among the nonthrower group).

Arthroscopic repair of posterior shoulder instability is effective. Improvements in stability, motion, strength, pain, and function were seen in patients with unidirectional instability. Pitchers who need stability with full motion may benefit from this type of procedure.

With the increasing number of total shoulder replacements, periprosthetic (near the implant) fractures are more likely. In this article, surgeons from Mayo Clinic review the types of fractures that can occur in the humerus (upper arm bone) after shoulder replacement and their treatment.

The risk of periprosthetic humerus fractures is increased with any of the following risk factors:

Overhead athletes are at risk for shoulder injury from repetitive motions with the arm in an overhead position. This can include baseball or softball pitchers, swimmers, or cheerleaders. Other athletes who repeatedly use an overhead motion of the arm are also at increased risk.

When the pain occurs along the back of the shoulder (posterior), it can be caused by injury to the rotator cuff, the labrum, or nerve entrapment. In this report, two orthopedic surgeons from Stanford University present four cases of quadrilateral space syndrome (QSS). QSS is another possible (but rare) cause of posterior shoulder pain.

A quadrilateral is any four-sided shape. In the case of the quadrilateral space of the shoulder, the top and bottom edges are formed by the teres minor (top) and teres major muscles (bottom). The long head of the triceps muscles is located along the medial (inside edge). The neck of the humerus (upper arm bone) is along the lateral (outer border) of the quadrilateral.

In QSS, the axillary nerve is being compressed or pinched as the nerve leaves this space. Pain occurs directly over the quadrilateral space. Symptoms are aggravated by overhead arm motion. There is tenderness when the area is pressed or palpated.

In this study, all four patients tried at least six months of conservative care without success. Electromyography (EMG), computed tomography (CT) scans, and magnetic resonance imaging (MRIs) were done to help make the diagnosis. Eventually a positive axillary nerve block identified the specific problem area.

Surgery to take the pressure off the nerve was done. The authors describe this decompression procedure in detail. During the operation, fibrous adhesions were cut away from the full length of the nerve. In one case, a dilated vein was also noted.

After the operation, gentle motion was started to prevent scar tissue from forming again. Active and passive motion was also used to keep the nerve and vein moving freely. The patients had to avoid overusing the arm for the first four weeks of therapy. By the end of six weeks, the therapist had prescribed a sport-specific therapy program.

Results were measured using pain and other symptoms. Range of motion, strength, and ability to return to overhead sports activities were also measured and compared before and after surgery. Twelve weeks later, all four patients were back to their pre-surgical level of sports activity. Everyone was pain free with full shoulder motion.

The authors point out that QSS can be very difficult to diagnose. This is true even with one (or more) arthroscopic exam(s). They offer a review of their own clinical decision pathway for this problem.

First, they take a history and perform a physical exam. Physical therapy is the first type of nonoperative care provided. If there’s no improvement with conservative care, then further testing includes an MRI and then a lidocaine block test. If the lidocaine block test is positive, then a CT angiogram is done to show the quadrilateral space and look for nerve compression.

A positive lidocaine block test is the most useful diagnostic tool. They also advise ordering a CT angiography with the arm in two positions: neutral (next to the body) and in the overhead position.

Dr. J. G. Skedros, an orthopedic surgeon from the Utah Bone & Joint Center in Salt Lake City has prepared three articles on the use of corticosteroid injections. The topic is the painful shoulder.

This is the first of those three articles. The focus is on the diagnosis, use, and misuse of these injections. The hope is to move toward a more uniform set of guidelines for such injections.

Corticosteroid injections are more powerful than using oral (by mouth) nonsteroidal anti-inflammatory drugs (NSAIDs). Besides reducing swelling, steroid injections also increase hyaluronic acid (HA) in the joint. HA improves waste removal from the joint and improves nutrition to the joint.

Injections take three to five days for the full effect to be felt. The relief of painful symptoms is both a treatment and a diagnostic test. Timing and dose are important. Too many injections, too close together, and with too high of a dose can lead to problems. Overuse of this treatment is the most common misuse.

Nonfluorinated corticosteroids must be used to avoid tendon rupture and wasting of the tissues (skin, fat, muscles) around the area injected. Steroid injections should never be used when there is an active infection in the skin or tissues around the shoulder. Patients with poorly controlled diabetes are not good candidates for steroid injections.

There are many possible local and/or systemic effects of corticosteroid injections. The author reviews each one carefully. The local effects include arthropathy (joint destruction), rotator cuff tendon problems, cellular effects, and corticosteroid flare (worse symptoms).

Adverse systemic effects can include uterine bleeding and menstrual problems, diabetes (new case or worsening for patients with diabetes), and reduced immune function.

The authors conclude there is a need for standard guidelines in the use of corticosteroid injections of the shoulder. Agreement is needed about when to use injections and how much to use. Uniform guidelines would help reduce the adverse side effects. Proper injection could lead to better pain relief and improved shoulder function.

Later issues of this journal will present parts two and three of this series. Physical exam and imaging will be discussed. Techniques for giving the injections in specific shoulder conditions will be presented.