News Category: Shoulder

Throwing athletes are at risk for a superior labrum anterior and posterior (SLAP) lesion. This is a tear of the labrum, the rim of cartilage around the shoulder socket. It is classified into four groups or categories depending on severity and associated soft tissue injury.

The most common SLAP injury is type II. This refers to a tear near the site where the biceps muscle inserts into the bone. Surgery to repair the damage is often needed. Making the diagnosis can be a challenge. Imaging studies such as magnetic resonance arthrography (MRA) are expensive. And an MRA isn’t always able to distinguish a SLAP tear from other problems. Arthroscopic exam gives a clear diagnosis but it is an invasive procedure.

There are many physical tests that can be applied by an examiner. In this study, 10 of those tests are evaluated alone and in combination with one another. The tests included Speed’s test, Yergason’s, anterior apprehension, relocation, compression-rotation, O’Brien, Kibler, biceps load II, Whipple test, and biceps groove tenderness. The hope was to find a single test or a group of tests that could reliably identify a type II SLAP lesion.

The authors described each of the tests. Each patient had a shoulder injury and had an arthroscopic exam to identify the problem. Two groups of patients were compared. The first group had isoated type II SLAP lesions or type II SLAP lesions along with some other injury. A second (control) group had a shoulder problem but did not have a SLAP lesion and the biceps tendon was not damaged.

Everyone in both groups was tested the day before arthroscopic surgery was done to repair the injury or injuries. All 10 tests were performed on each patient. The results were compared and analyzed for sensitivity (how well a test correctly identifies a condition), specificity (measure of the test’s effectiveness), and predictive values. Combinations of two and three tests were also analyzed for the same values.

The diagnostic accuracy of each test was reviewed for two different age groups (40 years old and younger, older than 40). Some of the tests were more accurate with younger patients. But there wasn’t one individual test that could diagnose a type II SLAP lesion. In other words, it wasn’t possible with any of these clinical tests to tell when the biceps anchor was detached. Results of combining tests weren’t any different between the two age groups.

The authors concluded that clinical tests are helpful but arthroscopic exam is needed to confirm a type II SLAP lesion. When choosing from among the 10 tests, two tests should be selected from the O’Brien, anterior apprehension, and compression-rotation tests. One test should be done from the Speed, Yergason,and biceps load II tests.

Only one test from the first group of three must be positive to be sensitive enough to suggest a type II SLAP lesion. If all three are positive, then the specificity increases. Using this method helps the examiner save time. Instead of performing all 10 tests, only three are really needed for good results.

When adults over the age of 50 injure their rotator cuff, how much of the soft tissue damage should be repaired? That’s the focus of this study, which may be the first to report results on rotator cuff tears (RCTs) with a superior labrum anterior and posterior (SLAP) lesion in patients older than 50.

A RCT refers to one of the four tendons that surround and help hold the shoulder joint in place. SLAP lesions affect the labrum, a thin ridge of cartilage around the shoulder joint. There are several types of SLAP injuries. In this study, only patients with a type II injury are included. Type II is a cartilage tear with an unstable biceps tendon anchor (place where it inserts).

The results of surgical procedures for RCTs with a SLAP lesion were compared. All patients were over age 50 and had both a RCT and a type II SLAP lesion. These injuries were diagnosed and confirmed with an arthroscopic exam. Size, shape, and type of tears were noted. The author described the arthroscopic technique used.

One group had both injuries surgically repaired. The second group had a RCT without repair of the SLAP lesion. Instead, the biceps tendon was removed from the labrum before the labrum was repaired. This procedure is called a biceps tenotomy.

Before and after assessments were performed for both groups using the UCLA shoulder rating scale. Pain, range of motion, and patient satisfaction were the main measures. Strength and function were also reported. Patients who had the tenotomy instead of a full repair had better overall results.

Follow-up was long enough (five years) to show outcomes after recovery was complete. Long-term follow-up was necessary because postoperative stiffness is common with these injuries. The study had to be long enough to track potential cases of postop stiffness.

As a result, the authors no longer see the need to repair a type II SLAP lesion in adults with a RCT after age 50. They found that it is possible to repair the RCT and leave the SLAP tear alone. Performing a biceps tenotomy along with the RCT repair may be all that’s needed for this age group.

Joint replacements are used more often with younger adults than ever before. But an even better treatment option are the new joint resurfacing implants. The entire shoulder joint isn’t replaced. The surface is smoothed and capped without removing the head of the humerus or the humeral shaft.

In this report, the results of cementless humeral resurfacing are reported. The 36 patients were all younger than 55 years of age. They were operated on by the same surgeon. They all had severe shoulder arthritis without osteonecrosis (death of bone cells).

Results were measured using pain, function, and patient satisfaction. X-rays were taken to look for any signs of implant loosening. Activity level for daily activities and sports participation was also reviewed.

Patients were followed for at least two years. Most patients were very satisfied with their results. Pain was less and function improved. There were some complications but nothing unusual or different from any other shoulder surgery. All but six of the patients were able to participate in sports activities at their desired level.

Long-term results with this treatment approach are not yet available. Short-term outcomes suggest that cementless humeral resurfacing is a good option. Young, active patients are happy with their motion, function, and recovery.

The actual limits of function and activity with humeral resurfacing remain unknown. There isn’t a specific list of dos and don’ts. It’s not clear yet how long the good results last. Collision sports are not advised because of the possible risk of fracture around the implant.

In time, the long-term results of this shoulder salvage procedure will become known. More studies are needed to compare joint resurfacing with total joint replacement. Studies are also needed to track patients having joint resurfacing at different ages and with different degrees of shoulder disease.

Patients who have had a prosthetic shoulder arthroplasty (shoulder replacement) have a generally high success rate after 15 years at about 87 percent. However, many patients do need to have revision surgeries because of infection in the shoulder, loosening of the hardware, or other problems.

In some cases, the patients’ shoulders are too damaged for further revision surgery and another option is needed. The authors of this study wanted to assess the function and pain status of patients who had a arthrodesis, or fusion of the joint instead of a revision surgery.

Researchers looked through files of patients who had had an arthrodesis performed following failure of the replacement. They found 7 patients who fit the criteria for the study. The patients ranged in age from 20 to 65 years and the follow-ups after surgery ranged from 18 to 96 months.

The researchers found that 5 of the patients had a union of the joint at the most recent follow-up recorded. However, only 3 patients were successful with the fusion after one surgery. The remaining 2 needed further surgeries for additional bone grafting. Two patients did not have a union (non-union).

Assessments of shoulder function and shoulder pain were done before surgery, after surgery, and during follow-ups. The researchers used the Penn Shoulder Score to assess pain, satisfaction, and function. The scores improved from 17 points (out of a possible 100) to and average of 58 points among the patients.

The authors point out that the small group size and the fact that this was a retrospective study are weaknesses of the study, however, they conclude that as a salvage procedure, glenohumeral arthrodesis is appropriate for carefully selected patients when other revision surgeries are not options.

The authors of this case study reported an undiagnosed fracture of the shoulder blade in a 15 year old hockey player with delayed union. He was allowed to return to playing hockey and seven months later was noted to have persistent shoulder pain, limited range of motion, weakness, and winging of the shoulder blade.

While shoulder blade fracture is rare and usually results from high velocity trauma such as a vehicle crash, the authors felt it important to demonstrate that persistent shoulder pain following any upper extremity trauma could be due to fracture of the shoulder blade. Shoulder blade fractures caused by severe trauma usually are associated with broken ribs, collapsed lung, and nerve and blood vessel injuries. Diagnosis may be difficult as plain Xrays may not show a fracture. Magnetic resonance imaging or computed tomography are more accurate in making the diagnosis.

Healing time for shoulder blade fracture is usually six to eight weeks but can depend on age, general health, and proper immobilization. Most can be treated conservatively using ice, heat, and immobilization followed by physical therapy for range of motion and strengthening. Surgery is rarely needed. However, when the diagnosis is not made initially, this can delay healing of the fracture.

In this study, orthopedic surgeons compare the results of using arthroscopic surgery to repair acute versus chronic shoulder dislocations. All patients dislocated the shoulder during trauma and ended up with a bony Bankart lesion.

A Bankart lesion means there is a fracture of the rim around the shoulder socket. A piece of bone attached to the cartilage pulls away. The result is usually an unstable shoulder joint that dislocates over and over.

With each dislocation, there is tissue trauma. Changes occur in the bone, capsule, and ligaments. This makes healing more difficult. Without surgery to repair the damage, athletes involved in various sports are at risk for redislocation.

Group A had an arthroscopic repair within the first three months after injury. Most of the patients in group A had a single dislocation. A few had up to three redislocations.

Group B were also treated with an arthroscopic repair but the surgery wasn’t done until much later. By then, most of the patients had three or more redislocations. One-fourth of the group had up to nine dislocations.

The results of this study suggest that arthroscopic treatment of acute Bankart lesions should be performed in the first three months. Traumatic shoulder injury that went untreated into the chronic phase had worse results when repaired later. They had less motion and decreased function. Fewer were able to return to sports at all. Those who did play participated at a lower level than before the injury.

Arthroscopic surgery for this type of repair is less invasive than open surgery. There is less soft tissue damage and a faster recovery time. The scope has a tiny TV camera on the end that sends the image to a computer screen. The repair can be done under direct vision. With clear access to the surgery site, the surgeon can restore the joint surface closer to the normal anatomy.

Fracture of the upper portion of the humerus (upper arm) bone can lead to serious problems. If the bone breaks into several pieces, there may be a collapse of the head of the humerus.

Anytime the head of the humerus is distorted or the fracture fails to heal, avascular necrosis (AV) can occur. AV is the loss of blood supply to the humeral head. Without this lifeline, the bone starts to die.

In this report, 38 patients are studied who had a total shoulder arthroplasty (TSA) (replacement) and who later developed AV. The researchers were looking for ways to predict (and prevent) a poor outcome after TSA for this type of fracture.

They used X-rays before and after the TSA to measure the shape and position of the humeral tuberosities. Tuberosities are bumps on the bone where muscles and ligaments attach. The shoulder has two main tuberosities: the lesser tuberosity and the greater tuberosity.

The results of this study showed that greater tuberosity malunion is a negative predictor of outcomes. In other words, for those patients who had this deformity, the final results were worse than for patients with normal or near normal tuberosity alignment.

Motion and function were both impaired by malunion of breaks in the upper humerus. X-ray measurements of greater tuberosity position called greater tuberosity offset (GTO) and posterior offset (PO) can be used as reliable predictors of clinical results.

The surgeon can use this test to identify potential problems and plan accordingly. There are other factors to consider but GTO and PO do affect prognosis. Using this information, patients can be told what to expect after surgery.

Surgeons continue to look for ways to repair rotator cuff tears (RCTs) that yield better long-term results. Studies have been done of the open repair, mini-open cuff repair, and arthroscopic repair. Results have been compared of short-term, mid-term, and long-term outcomes. Pain relief and improved function are the main measures used.

In this study, the multi-suture technique for rotator cuff repair is compared with open cuff repair. The authors wanted to test the idea that using multiple groups of sutures would disperse the force of the repair.

For a successful rotator cuff repair, the repair site must be stronger than the maximal muscle contraction force. Dividing the force across a larger portion of the rotator cuff tendon might reduce the total force across the rotator cuff crescent.

Three groups of cadavers were used. Cadavers are human bodies preserved after death for study. The surgeons cut a three-centimeter section of the supraspinatus tendon where it attached to the bone. This created an equal RCT in each shoulder.

Group one had the multi-suture method of repair. Three groups of four to five sutures were used to repair the torn cuff. Group two was treated with a three-suture technique. And group three was the control group with a normal rotator cuff. All three groups were equal in terms of age and gender.

A special DEXA scan was done to measure bone mineral density on all specimens. Previous studies have shown that a strong bridge of bone helps decrease the chances of the sutures pulling out of the bone. All cadavers had similar (adequate) density.

A special machine was used to apply an equal load to the rotator cuff tendon. The machine loaded the shoulder for two seconds over 3500 cycles. The load used was equal to two-thirds of the maximal force exerted by the rotator cuff muscles. The number of cycles mimics an average person’s daily activities involving the shoulder.

Results were measured by observing for failure of the cuff repair. A gap at the site of the repair was a sign of failure. A five-millimeter gap was a 50 per cent failure. A 10 mm (or larger) gap was defined as a 100 per cent failure.

The results showed that the multi-suture method is superior to the three-suture technique. A favorable environment for tendon healing is provided by the multi-suture approach. The technique is as strong as a normal rotator cuff tendon and stronger than provided by an open rotator cuff repair.

When failure occurred in the multi-suture group, it was for a variety of reasons. In some cases, the sutures pulled through the bone. In other specimens, the sutures failed at the tendon. In a small number of cases, fracture of the humeral neck occurred during the surgery.

The authors point out that the multi-suture technique is best suited for massive rotator cuff tears. It is not used in routine arthroscopic repairs. A strong enough bridge of bone is needed at the greater tuberosity of the humerus. This gives a stable base for the tunnels that must be drilled through the bone for the sutures to go through.

Finally, with the multi-suture method, the sutures must not be crossed but they should be tied to each other. This helps prevent a decrease in the strength of the repair site.

Using the multi-suture technique gives the patient a fixation strength equal to or greater than an undamaged rotator cuff. This may mean less time immobilized during healing and faster recovery. If the risk of fixation failure can be decreased in this way, the patient will have less shoulder stiffness. Faster return to normal activities and return to work or sports can be expected.

Tears of the glenoid labrum of the shoulder are common in athletes with traumatic shoulder injuries. The glenoid The glenoid is the portion of the shoulder blade that forms the shoulder socket. The labrum is a dense fibrocartilage ring that is firmly attached to the glenoid. It provides depth and stability to the shoulder joint.

When the labrum is torn along the posterior (back) or posteroinferior area, access to repair it can be difficult. Using an arthroscope to fix the tear often causes more damage to the labral tissue. In this article, a new technique is described that allows easy, safe access to this area.

The patient is positioned on his or her side. An arm traction device is used to give the surgeon a better view and better access to the area. A diagnostic exam of the shoulder is done using a standard posterior portal. Portal refers to the place where the arthroscopic needle is inserted through the skin into the joint.

In the standard arthroscopic labral repair, the surgeon makes a second portal just above the subscapularis tendon. This view makes it possible to see if the posterior labrum can be reached. The scope is then placed in the posterosuperior portal. This gives a good view of the posteroinferior quadrant.

Although the view is good, getting to the labrum where it attaches to the bone is not a straight shot. Angling the scope in to that area can cause additional tearing and damage to the labral tissue.

An alternate method is proposed here. The surgeon doesn’t use the posterior portals. Instead, a mid-glenoid or anteroinferior portal is used to find the tear. This portal allows the surgeon to slide the arthroscopic tools directly across the glenoid.

From there, the labrum can be lifted off the glenoid. A special tool called the arthroscopic elevator can reach under the posterior labral tissue. This allows the surgeon to get under the chondrolabral junction where the labrum attaches to the bone. The bone is shaved to smooth it. The rest of the repair can be done using the standard posterior portals.

The surgeon must watch for incomplete tears or cracks in the posterior labrum. These can also be repaired using the elevator device through the anterior portal.

The authors conclude that the anterior portal can be used to reach the chondrolabral junction. This makes preparation of the area for repair easier to perform compared to the standard posterior approach.

Humeral avulsion of the glenohumeral ligaments (HAGL) is a rare but serious cause of shoulder injury. Avulsion means the ligament is torn away from the bone. The result is repeated shoulder dislocation. This type of shoulder instability usually requires surgical repair.

In this article, surgeons present a new way to describe and classify HAGL lesions. They call it the West Point nomenclature. Nomenclature is another word for classification or groups.

Six patient case studies and a review of the current literature were used to develop the classification scheme. A total of 71 patients were included.

The HAGL lesion often occurs with other shoulder injuries. For example, the patient may have suffered a rotator cuff tear or a tear of the labrum (rim of cartilage around the shoulder socket). If it goes unrecognized and unrepaired, symptoms may persist even after surgery is done to reconstruct the shoulder.

The authors of this report give a thorough anatomical review of the glenohumeral ligaments. They also describe the many forms of HAGL injury. The goal is to improve clinical decision-making regarding treatment.

They found six separate forms of HAGL lesions. Damage to the anterior or posterior band of tissue was one of the distinguishing features. Two other forms involved a rupture of a tiny piece of bone along with the ligament and a tear of the labrum. Each of these additional injuries was given a name such as anterior bony HAGL, floating anterior inferior HAGL, or posterior bony HAGL.

The more specific the injury can be described, the more likely the right treatment can be applied. With accurate information, the surgeon can decide which is better for the patient: conservative care or surgical management. When surgery is required, the surgeon can use this method of classification to determine which repair is needed.

In this study, the results of open versus arthroscopic repair of anterior shoulder instability is compared. The main measure used was muscle strength.

Patients with anterior shoulder instability were divided into two groups. Anterior shoulder instability means there is chronic shoulder dislocation in a forward direction. Both groups had surgery to repair the damage. The name of the operation is a Bankart repair.

The first group had an arthroscopic Bankart repair. A thin needle is inserted into the joint. A tiny TV camera on the end gives the surgeon a clear view of the structures. The second group had an open repair. An incision is made to cut open the skin and soft tissues underneath.

Some studies have compared the results from these two methods. This is the first to look at muscle strength. Patients were followed up to 12 months after the operation.

The results showed that muscle strength recovers faster after an arthroscopic Bankart repair. Strength was back to normal at six months for the arthroscopic group. Muscle strength was slower to recover in the patients who had an open Bankart repair. But by the end of 12 months, there was no difference between the two groups.

The authors suggest that recovery after an open repair takes longer because damage to the soft tissues is greater. The subscapularis muscle responsible for internal rotation is especially affected.

But once the subscapularis tendon and muscle heal, then strength recovers fully. Weakness of the internal rotator muscle may be prolonged if there is scarring or shortening of the subscapularis tendon after the operation.

Shoulder rehab can start sooner and progress faster after an arthroscopic Bankart repair. Contact sport activities can begin as early as three to four months after this method of repair. Close supervision during rehab is advised to promote faster functional return without complications.

Falling directly onto the shoulder often causes fractures of the greater tuberosity of the humerus (upper arm bone). This is called an impaction injury. The greater tuberosity is a bump on the bone.

Several shoulder muscles from the rotator cuff attach to this part of the bone. The rotator cuff is made up of four muscles that surround the head of the humerus. The rotator cuff moves the arm and helps hold the bone in the shoulder socket.

Other injuries such as a shoulder dislocation can also cause greater tuberosity fractures. This type of trauma is called a shear injury. In this review, Dr. Michael S. George from the University of Texas Medical School (Houston, Texas) explains the management of greater tuberosity fractures.

How the fracture occurs and the medical classification of these injuries is discussed. A brief review of the anatomy is provided. Once the diagnosis is made, then treatment is decided.

Range of motion is important to avoid a frozen shoulder. The patient may need a sling to immobilize the shoulder for a few weeks. This is followed by rehab with a physical therapist. Surgery may be needed when pain persists.

Most fractures of the greater tuberosity heal well without surgery. If the shoulder is dislocated, the surgeon can use a special maneuver to put it back in place. The pressure of the humerus up into the socket holds the fracture in place until it heals.

But there may be other injuries to the soft tissue structures around the shoulder. There may be a partial or full tear of the rotator cuff. Sometimes the rim of fibrocartilage around the shoulder is torn. Even after rehab, pain and weakness can occur. Shoulder instability leads to a loss of function.

In such cases, surgery may be needed to repair the damage. If the fracture hasn’t healed, then screws, sutures, or wires may be needed to hold the bones in place until healing can take place. Bone fragments may have to be removed.

Rotator cuff repair may be required. The repair can be done arthroscopically or with an open incision. The author reviews the position and procedures used for both surgical methods. Studies to compare the results using these two methods have not been done but are suggested for future investigations.

This article is the third in a 12-part series. The topic of the series is commonly injected joints. The focus of this report is the shoulder. Shoulder pain can be difficult to diagnose. An injection can help isolate and treat the problem. A numbing agent like Novocain is used. It is combined with a steroid to reduce inflammation.

There are three sites in the shoulder region that can be injected. These include the glenohumeral (GH) joint, the acromioclavicular (AC) joint, and the subacromial space.

The location and anatomy of each of these sites are described. Supplies needed for each area are provided. Needle size, specific drugs, and medication dosages for each are also included.

The authors offer reasons for their instructions. For example, a triamcinolone-based steroid is used for the GH. It is the longest lasting injectable corticosteroid. A nonfluorinated corticosteroid is used for the subacromial space. It reduces the risk of tissue loss and skin changes.

Patient position and placement of the needle are described. The examiner is told how to use the surface anatomy to feel for the exact spot to inject. If there is fluid in the joint, it is aspirated (drawn out) first before injecting the drugs.

The procedure is done with sterile technique. The skin is anesthetized (numbed) so the patient does not feel the injection. Synovial fluid from inside the joint is sent to the lab for analysis. This information can help with the diagnosis and treatment plan.

The authors provide other pearls (tips) as well. For example, positioning of the patient and examiner is described that allows easier needle entrance into the joint.

A popping sensation is not uncommon when injecting the subacromial space. This is caused by the needle entering the bursa. The bursa is a small fluid-filled sac. It’s located where a muscle or tendon slides across bone. Th bursa is a cushion to reduce friction between the two moving surfaces.

Loss of motion and function occur with adhesive capsulitis. This condition is also known as frozen shoulder. Experts in physical therapy have suggested that a treatment technique called mobilization may be helpful.

Mobilization is a therapeutic movement of the joint. It’s a back-and-forth oscillating movement done within the available joint range of motion. And it’s done by the physical therapist at a speed the patient can control. Mobilization can be used to stretch the shoulder capsule and soft tissues. The goal is to restore normal joint motion and rhythm.

This is the first study to evaluate the use of three mobilization techniques. Two of these methods (mid-range mobilization (MRM), end-range mobilization (ERM)) are done in slightly different positions of the joint. The third mobilization is performed along with joint motion (mobilization with movement (MWM)).

Patients with frozen shoulder syndrome were randomly placed in two different groups. Each group received two or more mobilization techniques. This is called a multiple treatment trial. Each mobilization method was performed twice a week for three weeks. The sessions lasted 30 minutes.

Outcomes of the treatment were measured based on patient report of function and computerized motion analysis. The results showed improvement in motion and function for all three techniques. ERM and MWM worked better than MRM. MWM improved the quality of shoulder motion.

The authors conclude that ERM and MWM are the only mobilization methods that successfully stretch the joint capsule and surrounding soft tissues. Both should be used together. MWM also improves the rhythm of motion between the shoulder joint and the shoulder blade.

The goal of orthopedic surgery, repairs and replacements, is to minimize or eliminate pain and to help patients regain the use of the affected limb. Researchers in earlier studies have looked at how successful knee and hip surgeries are in relation to the patients’ expected outcome. They found if a patient expects the surgery to be successful, the chances of the success are higher than if the patient was doubtful. No such studies have been found regarding rotator cuff repairs, or repair of the shoulder.

The authors of this study wanted to see if how the expectations of patients who were undergoing surgery to repair the rotator cuff would affect the outcome of the surgery. To do this, the researchers enrolled 125 patients who had symptoms of a rotator cuff tear for at least 3 months and they could not have had previous surgery. The patients ranged in age from 32 to 84 years; the average age was 56. The majority of the patients (72) were male and the length of time that the injury was present ranged from 3 months to 210 months.

Before the surgery, the patients were evaluated with a medical history, physical examination and questionnaires completed by the patients. The questionnaires included the Simple Shoulder Test (SST), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, visual analog scales (VAS) for shoulder pain and shoulder function, the Short Form-36 (SF-36, which evaluated overall health, and 6 questions from the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) questionnaire, which evaluated patient expectations.

Among the group, 26 patients had an open repair, the more traditional type of surgery, 62 had a mini-open repair, which involves a smaller than usual incision, and 37 had arthroscopic repair, which involves very small incisions to allow the surgeon to insert instruments with a camera to visualize what he or she is doing.

Following surgery, all patients used slings and went for physiotherapy to begin range-of-motion exercises the day after surgery. The patients were not to actively use their affected arm for 5 weeks.

When the patients were re-evaluated after the recovery period, the researchers found that the majority of the patients had high expectations regarding the success of the surgery and more than 85 percent felt that success was very likely or extremely likely. The majority of patients showed significant improvements on the various measurement scales. The better the expected outcome expressed before surgery resulted in better post-surgery performance, the researchers noted.

The authors conclude that the patients’ expectation before surgery does affect their perception of the surgery’s success. They do point out that the study has some weaknesses, foremost the possible differences in the tendons themselves, the actual surgery, and even the surgeon’s approach to the surgery.

Rotator cuff tears, tears in the tendons that support and help the shoulder move, are a common injury, brought on by repetitive and/or forceful movements. While many people undergo surgery for massive tears, treatment without surgery may be an option for many. The authors of this study wanted to see how the shoulder itself fared after non-surgical treatment.

The researchers originally enrolled 40 patients into the study of nonoperative management for massive rotator cuff tears. Seven of the patients decided to have surgery because of increased pain and/or difficulty moving the shoulder, 4 patients died before the end of the study, 3 could not have the magnetic resonance imaging (MRI) test for follow up, and 7 refused to have the MRI. That left 19 patients for evaluation. They ranged in age from 54 to 79, with the average age being 64 years. Twelve of the patients were men. Three patients had a gradual development of symptoms and 16 sustained their injury through an accident. Six patients had 2 tears and 13 had 3 tears.

Among the patients, all of the tears were considered to be reparable through surgery or irreparable; 8 patients had reparable tears while 11 had irreparable tears.

Before the study began, the patients underwent a physical exam and standard x-rays of the shoulder, as well as an MRI. At follow-up, anywhere from 30 to 65 months later, the patients underwent the same x-rays and MRI, and a shoulder scoring system called the Constant and Murley. The researchers found that, on the whole, most patients were able to continue with satisfactory shoulder function without having had surgery. Through the x-rays and MRIs, the researchers did find deterioration in the shoulder, but this did not seem to have a big effect on the patients’ function. They also found, however, that some of the reparable tears had become irreparable over the study period.

The authors point out that their study was not meant to compare surgery with non-surgery treatment, but to study the actual shoulder to see if there were any physical changes as a result of the nonoperative treatment approach.

Is it possible to predict who might dislocate the shoulder a second time? Should surgery be done to keep this from happening? These are the questions the authors of this study attempted to answer.

Surgery to repair damage to the shoulder could save the patient the suffering of re-dislocation and the cost of multiple doctor visits. But it’s important to avoid surgery when it’s not needed, too.

There were 131 patients in the study who had first-time shoulder dislocations. Data of all kinds was collected on everyone. Age, body type, joint flexibility, and occupation were just a few pieces of information collected. A detailed report of the dislocation event and type of damage done to the joint was also included. The number of sports hours played was also recorded.

Everyone was followed for at least two years. A research assistant telephoned each patient every six months to ask a few questions. The authors thought it would be better to avoid relying on the patient’s memory and collect the data directly instead.

Some patients were still in the study for five years. Each patient was asked to come back to the clinic for a follow-up exam. Analyzing the data and looking back, there wasn’t really a way to predict who might dislocate the shoulder again.

Younger patients who were involved in contact or collision sports were more likely to re-dislocate the shoulder. The same was true for younger patients whose job required them to work with their arms overhead. But not all of these patients needed surgery, so these factors aren’t enough to suggest surgery is needed.

Those who did have surgery did not dislocate the shoulder again. And looking back over all the data, the researchers were never able to see any differences between those who had surgery and those who didn’t that might help predict future instability.

Trauma with dislocation of the shoulder is a major cause of tendon tears in the shoulder. Damage to the subscapularis muscle is the subject of this study. Previous studies have shown that more than half the patients with a subscapularis tear also have biceps tendon instability. Instability is defined as a subluxation, dislocation, or rupture of the tendon.

Surgery is needed to repair these two problems. If only the subscapularis tendon is repaired, the patient may end up with soreness and spasms from an unstable biceps tendon. Cutting the biceps tendon or sewing it back to the bone often has poor results.

The authors of this study suggest saving and stabilizing the biceps tendon. They do this at the same time they repair the subscapularis tendon. They advise early treatment for the best results. A description of the procedure is given. The operation included refixation of the subscapularis and reconstruction of the biceps reflection pulley. Photos and drawings are included to show the technique.

This is the first study to report combined subscapularis and biceps tendon repairs. Compared to results of just the subscapularis repairs, function was improved about the same. The main difference was in patient comfort and appearance. With the additional biceps tendon repair, patients no longer had a Popeye bulge in the biceps. And they had less discomfort from spasms.

Follow-up clinical exam, X-rays, and ultrasound imaging are advised. The authors warn of the need to watch out for re-rupture. Some patients needed further surgery. This is especially true for those who delayed stabilization of the initial injury.

In this study, the value of magnetic resonance imaging (MRI) was measured in testing for thoracic outlet syndrome (TOS). TOS is a condition caused by pressure on the nerves and blood vessels as they leave the neck and travel down the arm.

With TOS, symptoms of neck and arm pain, numbness and tingling, and swelling in the hands are common. Weakness of the arms is also reported. All symptoms present are made worse by working with the arms overhead. Fatigue and stress can also make the symptoms worse.

Doctors rely on clinical tests to diagnose TOS. These are called provocative tests because they put the patient’s arm in a position that will put pressure on the nerves and blood vessels, bringing on the symptoms.

Scientists are studying the various tests used to diagnose TOS. They hope to find one or two tests that can be relied upon to test for TOS. MRI may be one of those tests. In fact, the results of this study showed that MRI findings are valuable in the diagnosis of TOS.

Two groups of subjects were included in the study. The first group had a known diagnosis of TOS. Group 2 (the control group) were normal, healthy adults with no known TOS and no current symptoms of TOS. MRIs were taken for both groups in two positions. One was lying down with the arms at the sides. The second was taken with the arms overhead. This is one of the provocative test positions.

As expected, there was a big difference between the TOS group and the control group. And there was a significant difference in the TOS group between arms down at the sides and arms overhead. The control group showed signs of vascular compression but no nerve compression.

The authors conclude that MRI can give good information about vascular or neural structures in the area of the thoracic outlet. It can show the presence of fibrous bands across the blood vessels and nerves that might be causing the problem. It is not necessary to do the MRIs with the arms down at the sides. Only MRI images with the patient in the provocative position are necessary.

Thanks to the availability of arthroscopic surgery, the surgical treatment of acromioclavicular (AC) separation is changing. The AC joint is where the end of the collar bone (clavicle) meets the acromion. The acromion is a bony projection from the shoulder blade. It curves around over the top of the humerus (upper arm) where the humerus sits in the shoulder socket.

Injury to this site can cause a rupture of the ligament holding the two bones together. This is called a shoulder or AC joint separation.Less invasive methods are being developed for this problem. In this article, orthopedic surgeons specializing in shoulders review the latest techniques for the treatment of AC joint separations.

Most surgeons agree that nonoperative treatment is still the best plan whenever possible. Surgery may be needed for more severe injuries. When needed, early operative treatment has the best results. Athletes may opt for surgery if the injury occurs at the end of the season. This will help get them back to play for the next season.

The authors review three types of operations that can be done for AC separations. The first is the one used most often. It’s called the Weaver-Dunn reconstruction. This involves the transfer of a ligament to repair the problem.

The second operation uses a piece of tendon looped around and tied in placed or placed through a tunnel cut in the bone. The third method of operative repair is with the use of an endbutton to put the clavicle back in place and hold it there while it heals. This works better than the old method using wires or screws. It holds better with fewer problems during healing.

Specific information about how to do each procedure is included in this article. Studies have not been done to compare all three methods. A few studies have compared two of the surgical methods.

None of the operations described restore the AC joint. In cases where pain persists, it may be necessary to remove the end of the clavicle. Arthroscopic methods are less invasive but they cost more. And it’s not clear that the results are any better than open repair. More research is needed in this area.