News Category: Shoulder

This report reviews conditions of the sternoclavicular joint (SCJ). The SCJ is the joint between the collarbone and the sternum or breastbone. It’s the only place where there’s a bony connection between the arms and the main body. All other connections are fibrous or cartilage, not bone. Problems in this joint may or may not be painful or symptomatic.

Problems at the SCJ occur more often the older we get. Arthritis (osteoarthritis and rheumatoid arthritis) is the most common condition affecting the SCJ. Infection, dislocation, and gout can also occur at this joint.

The authors present signs and symptoms and risk factors for each of these conditions. They also include some of the more rare problems that can occur such as Friedrich’s disease, condensing osteitis, and cancer.

Treatment is usually for the symptoms and may include rest, anti-inflammatory drugs, or antibiotics (for infection). Surgery is rarely an option but may be needed in cases of severe pain that doesn’t respond to other treatment measures.

Doctors and physical therapists often see patients with shoulder pain. Treatment gets better results when there is a known diagnosis. In this study, selective tissue tension (STT) is evaluated as a reliable way to make that diagnosis.

STT includes tests of movement and muscle control of the neck and shoulder. It’s a logical way to examine the shoulder. One expert and three other examiners (doctors and physical therapists) used the STT to evaluate 56 shoulders. All four examiners came up with a diagnosis based on the results of the STT.

There was overall good agreement among them. But a closer look at the data showed there wasn’t agreement for all diagnoses. Agreement was only fair-to-moderate for shoulder bursitis. Shoulder capsulitis seemed to have the best agreement.

The authors suggest the STT can be used to diagnose shoulder problems when the examiner is experienced. Competence in the use of the STT can’t be taken for granted. The test may be more reliable than the examiner using the test. For this reason, training in the use of the STT is needed before using it to diagnose shoulder problems.

Rotator cuff (RC) tears are very common in adults of all ages. Many RC tears are repaired arthroscopically using suture anchors to reattach the tendon to the bone. These anchors can be made of many different materials such as metal, plastic, and bone.

In this study Dr. Bonutti used a new suture anchor he designed himself to repair 63 torn RCs. The new anchor is made of allograft material, which means it’s made of bone taken from a donor. It is machine-shaped with a straight bottom and pointed top. The sharp tip makes it possible to insert into the shoulder bone without drilling a tiny hole first.

Once in place the anchors stayed in place. They seemed to become part of the host bone, but didn’t replace it. Over time the anchor was no longer visible on X-ray. The researchers tested it on cadavers first before using it in live humans. In this way they could find out how much load the anchors could take before breaking.

The Food and Drug Administration approved the anchors. Using this type of suture eliminates the need to drill a hole in the shoulder bone first before reattaching the tendon. When the bone is too thick a small pilot hole can be made first using a surgical awl. The direct insertion method is safe and effective and saves time in the operating room.

Physical therapists (PTs) believe that the forward position of the head and neck affects shoulder movement. Shoulder pain often comes from a problem called subacromial impingement syndrome (SIS). PTs use a program of postural exercises for SIS, but there’s no proof that this method works. This study examines the effect of changing posture on shoulder motion.

SIS occurs when the arm is raised up overhead. Soft tissue structures get pinched between the shoulder and the acromion. The acromion is a curved piece of bone located over the top of the shoulder. By restoring normal posture PTs hope to reduce the symptoms of SIS.

Two groups of subjects were studied. One group of 60 adults had no problems with their shoulders. The second group of 60 adults had a known case of SIS. A photograph was taken from the side of each person to show the angle of a forward head posture. Shoulder range of motion was measured for everyone. Pain levels were recorded for the subjects with SIS.

Taping of the spine and scapula(shoulder blade) was done on everyone. In the treatment group taping was done to correct the forward posture. In the placebo group, tape was applied to the same places but without correcting the person’s posture. Everyone was photographed again for before and after comparison.

The authors report no change in motion or posture with the placebo taping. Taping with a changed posture for the SIS group did make a difference in shoulder range of motion but not pain levels. There’s still no evidence that taping makes a difference on posture during movement.

What do total hip and total knee replacements, hip fractures, and total shoulder replacements have in common? Problems after surgery are less in hospitals where surgeons do high volumes of these surgeries. Patients having these operations in high-volume hospitals also stay in the hospital for fewer days. In this study the state of New York confirms this fact for total shoulder replacements.

Over 1,000 cases of total shoulder arthroplasty (TSA) were reviewed by the New York State Department of Health. They looked at length of hospital stay and costs. They also counted the number of patients brought back to the hospital within the first two months. Other measures included number of second surgeries needed within two years of the TSA and number of deaths within two months.

They found that younger patients are more likely to have surgery at high-volume hospitals. A high-volume hospital averaged 42 TSA patients each year. Hospital stay was longest in patients at low-volume hospitals. A low-volume hospital did between one and 15 TSAs each year.

The cost for TSA varied based on whether the operation was done at a low-, middle-, or high-volume hospital. The middle-volume hospitals had the lowest charges. Readmission, revision surgery, and death were lowest for high-volume hospitals.

This was the first study to show a link between increased volume of TSAs and low rate of problems after the operation. This type of study helps public health officials make policy decisions.

In 1997 Japanese researchers started a study of high-risk athletes with chronic shoulder instability. Arthroscopic surgery was done to repair the shoulder using special suture anchors or “buttons”. The purpose of this study was to look at the results of the operation, especially the athletes’ sports activities.

Only certain athletes were allowed in the study. They had to be younger than 25 years old or involved in overhead or contact sports. They all had at least one (sometimes more) partial or complete shoulder dislocation. They couldn’t be included if there was major bone loss around the front of the shoulder joint. Failed surgery or a previous rotator cuff repair also kept athletes out of the study.

The final selection included 55 athletes who had surgery to repair a torn glenoid labrum. The glenoid labrum is a rim of cartilage in the shoulder joint. It helps deepen the shoulder socket and gives a place for some of the shoulder tendons and ligaments to attach. Patients were followed for up to six years. All patients wanted to get back to their sports activities but were limited by their unstable shoulders before the operation.

The authors describe the method used to repair the damage with special suture anchors. Patients were given instructions for activities and exercise for the first three months after the operation. They were allowed to go back to sports at four to six months.

Results were measured based on pain, stability, range of motion, and return to sports. Slightly more than 80 percent had excellent results. These athletes returned to their sport without restrictions. A few patients had another shoulder dislocation after recovery from the surgery. Overhead athletes were more likely to have a fair to poor result.

The authors conclude that the arthroscopic repair using a suture anchor to stabilize the shoulder works well for some athletes. Selecting the right patients for this operation is a key to success in returning to full sports activities.

If you have a hand injury does it stand to reason that your shoulder will be weaker? If the shoulder is weaker is it directly linked to the hand injury?

That’s what this study is all about. Dr. Budoff from the Department of Orthopaedic Surgery at Baylor College of Medicine in Houston, Texas, put these questions to the test. He measured rotator cuff strength in 57 patients with a hand or wrist injury. The rotator cuff is made up of four muscles that surround the shoulder.

A handheld device called a dynamometer was used to measure grip strength. The dynamometer is known to be an accurate way to measure arm and shoulder strength. Each test was done three times with a 30-second rest in between all tests. Studies show this is the best way to measure upper extremity strength.

Other strength tests were also done. Each muscle of the rotator cuff was tested separately. Each type of injury was recorded along with which hand was dominant. About half the patients were on worker’s compensation.

The results showed younger patients had a greater strength loss. This may be because they have more strength to lose than older patients who are weak to start. The type of injury (muscle versus bone) didn’t seem to affect muscle strength. Shoulder weakness was greater when the nondominant hand was injured.

This study showed a significant loss in shoulder strength for the arm with an injured hand or wrist. Dr. Budoff isn’t sure why this happens. It could be hand injuries lead to decreased use of the arm. The limb gets deconditioned. The rotator cuff gets weak and tired. He suggests starting a program of shoulder exercises sooner than later.

Long-term results of rotator cuff repair are the subject of this study. How well do patients 50 and younger do years after the repair? How many fail to get pain relief or improved motion? What are the risk factors for those who don’t have a good result?

Thirty-six shoulder repairs were followed for at least 13 years. All had a full-thickness tear of the rotator cuff, the group of muscles and tendons around the shoulder. Types of tears (shape and size) and types of repairs were reviewed in this article.

An excellent result from the surgery was defined as a shoulder with no pain and good motion. Patients with a poor or unsatisfactory result had pain and loss of motion. The results of rotator cuff repair in these young patients were not good. More than half had a poor result. One out of every four patients had another surgery after the first one. Patients who had relief from pain didn’t necessarily gain motion.

What are the risk factors for a poor result? The authors report that it’s not the size of the tear, type of repair, gender of the patient, or whether the injury was work-related.

Pain and loss of motion and strength seem to be the biggest factors in patient satisfaction. The authors conclude that the main benefit of rotator cuff repair is long-term pain relief. Improved motion and strength may not occur. Rotator cuff repair in younger patients doesn’t seem to have the same good results as in a more mixed-age or older age group.

Can athletes with a dislocated shoulder get back into the game? Can they do this without surgery? During the same season? Doctors who work in sports medicine put this question to the test. They treated 30 athletes with shoulder instability from a partial or complete dislocation. Physical therapy and bracing were used as treatment options.

All players were competitive athletes at the high school or college level. All wanted to return to their sport during the same season. Measures used included: 1) the player able to return to the same playing position at the same level of play; 2) number of days missed; and 3) number of times the same shoulder dislocated again.

The authors report that 90 percent of the athletes returned for part or all of the season. The average number of days missed before getting back to the field was 10. One-third of those athletes had at least one more sport-related shoulder dislocation. Half of the athletes ended up having surgery later during the off-season.

The authors say that athletes with shoulder instability can return to their sports without immobilization or surgery. The athlete can delay surgery until the off-season without further damage to the shoulder.

Pain along the back of the shoulder is a common problem in overhand athletes. The problem could be a torn rotator cuff (RC). It could be frayed edges on the rim of cartilage called the posterior labrum (PL). Sometimes both problems are present at the same time.

Doctors are looking for a test to help identify posterior RC or PL tears. In this study the posterior impingement sign (PIS) was tested. Patients were divided into two groups by injury type, either contact or noncontact. Each athlete was tested using the PIS. Then the shoulder was examined using an arthroscope. This tool allows the doctor to look inside the joint and see what’s going on.

The authors report that the PIS doesn’t work for everyone. It’s most accurate when used with young, overhand athletes. They present with a gradual onset of posterior shoulder pain. In this group, a positive PIS indicates a partial tear in the RC or PL. Using the test with older adults isn’t advised. Degenerative changes from aging can be the real problem.

Thermal capsulorrhaphy (TC) is a way to heat the shoulder capsule and tighten it up. Doctors at the Center for Shoulder, Elbow, and Sports Medicine at Columbia University in New York City reviewed this treatment method. They presented the basic science behind it and how it’s used. Results and concerns about problems with TC were also covered.

Heating up the shoulder capsule has been around since the days of Hippocrates (400 BC). Its use has become popular again in the last 10 years. But Hippocrates used a white-hot poker for his treatment. Today’s doctors use laser or radiofrequency (RF) heating. A probe is used to deliver the RF. The capsule is heated to about 65 degrees Celsius (150 degrees Fahrenheit). The collagen fibers in the capsule shrink at this temperature.

These authors reviewed studies done in the past 10 years on animals, cadavers, and athletes. The results show that heat treatment to shrink the capsule has major problems. There can be loss of cartilage and joint destruction. Nerve damage can occur. The capsule can be so damaged that it won’t even hold together with stitches later.

Long-term results for TC show this treatment isn’t as promising as once reported. Doctors are back to the drawing board looking for better ways to treat shoulder instability.

Studying patients over a long period of time helps researchers find out what treatment works and why. This is the second part of a study done on shoulder patients. Patients with shoulder pain were treated with exercise, mobilization, injections, and electrical therapy. The results of treatment were measured and reported.

Now the same group of patients agreed to continue in the study. The purpose of the study was to see what happens six months after treatment stopped. At the same time, the researchers looked for any factors that might predict the results.

Everyone in the study had pain in one shoulder that was made worse with movement. Some had pain that went into the upper arm on the same side. Some patients still had stiffness and loss of motion after treatment during the first study, but before this study began.

Possible factors linked to outcome included hand dominance, how long the patient had the symptoms, and previous shoulder pain. Age and muscle force were also factors the researchers looked at. Researchers looked at results including pain level, function, and strength. Each patient also rated how hard it was to perform nine tasks using the shoulder and arm.

Results from measurements taken before treatment began were compared to the same tests six months after treatment ended. All measures improved in the long run. Patients with shoulder pain and stiffness or shoulder pain without stiffness all showed good improvement.

The authors did not find any factors to predict who would get better. In general, age might be a factor. The older patients were less likely to have a good result. But this doesn’t apply to everyone, since more than half of the older subjects had a good result in this study. It may be that the treatment can be credited for the success of these shoulder patients. More study is needed to answer this question.

Pain relievers. Injections. Steroids. Physical therapy. Stretching. Strengthening. That’s the trail of treatment for adhesive capsulitis otherwise known as a “frozen shoulder.” When it’s truly “stuck,” manipulation may be needed. It can be a long, frustrating journey for the patient.

This is a report of 40 patients with resistant adhesive capsulitis. All were treated with manipulation and release of the joint capsule. A rehab program followed.

In a manipulation, the patient is anesthetized. The surgeon moves the patient’s shoulder through its full range of motion. The arm is relaxed, and scar tissue is popped or torn as the joint moves freely. The surgeon may also use an arthroscope to reach inside the joint and cut the capsule loose. This release prevents bone fracture, torn muscles and tendons, and dislocations that can occur with shoulder manipulation.

The results of this treatment were measured by stiffness, pain levels, motion, and function. An important focus of this study was the method and timing of physical therapy (PT) after the operation. In this study, PT started the first day after surgery. Rehab went through two phases over three months.

The authors conclude that the combined treatment of manipulation, capsular release, and early rehab works well in rare cases of resistant frozen shoulder. The patients regained most of their shoulder motion and were very happy with the results.

Two doctors from Austria present the results of a special operation to repair a torn rotator cuff in the shoulder. Arthroscopy allows the surgeon to repair torn tendons and muscles without cutting the shoulder open. There are many advantages to this type of operation. This article presents the results for 84 patients after three years.

All patients in the study had tried treatment with drugs, injections, and physical therapy before the operation, with no success. The same repair method was used in each surgery. A newer technique of knot tying for the sutures was used.

During the operation the surgeons took careful note of many factors. They measured the size of tear and recorded what kind of tear it was. They looked at the quality and movement of the four tendons in the rotator cuff. The number of sutures and the types of knots used to hold the repair in place were recorded. These findings were compared to X-rays taken before and after the operation.

The authors report good results with this repair method. Pain, motion, and everyday function were just as good after this operation as with other techniques. Results depended on the size of the tear and the shape of the acromion. The acromion is a bone that curves over the top of the shoulder and connects to the collar bone.

This study showed that arthroscopy can be used even for medium to large tears of the rotator cuff. The surgeons report that the specific technique they used gives a better chance for healing. After three years, their patients still had a tension-free and stable repair. A study of long-term results is still needed to see if the repair holds up over time.

This study reports the results of 71 shoulder joint replacements. All were done by one surgeon. The goal was to find factors present before the operation that are linked with positive results after the operation. If such factors can be found, then surgeons can help patients make better decisions about surgery.

The surgeon used a humeral head implant in all the shoulder replacements. A stem was also inserted into the upper arm bone. The patient’s socket (glenoid) wasn’t changed. This operation is called a hemiarthroplasty. The same surgery was used for each shoulder. Follow-up rehab was also the same for each patient.

Comfort and function were the two main measures of success. Here’s what the researchers found:

When you take a medication, it’s usually for a reason. Pharmacists tell you what to take and how much to take. Exercise can be dispensed in the same way. Specific types of exercise in known amounts can be prescribed to prevent or treat muscle injury.

Physical therapists at the American Sports Medicine Institute (ASMI) are leading the way in exercise prescriptions. They used electrodes to measure muscle activity of four shoulder muscles. Ten subjects with normal shoulders were measured during seven shoulder rehab exercises.

The goal was to find which exercises work the best to increase strength in the shoulder. Researchers looked at commonly used exercises for shoulder external rotation. They found that muscle activity was different for all seven exercises. They were able to find which exercises worked best for each muscle.

This information will help physical therapists choose the right exercises to strengthen the shoulder without pinching the joint capsule or putting upward pressure on the joint. The best position for each exercise is also reported.

When the shoulder is injured, the head of the humerus can shift in the socket. This may lead to changes in pressure points inside the joint. In this study, scientists from Munich, Germany, took a closer look at what happens after shoulder injury.

The authors used CT scans and computer programs to measure and map the thickness (density) of bone in the shoulder joint. Two groups were compared. The first group had minor or major trauma to the shoulder leading to forward (anterior) dislocation. All patients had surgery to repair the shoulder. The second group was the same age with healthy shoulders and no sign of trauma or injury. A special CT scan called osteoabsorptiometry was used to measure bone density. The shape of the shoulder socket was also mapped.

The researchers found a change in bone density for the injured shoulders. They report a shift forward of maximum joint contact for patients with major trauma. There was a downward shift for patients with minor trauma. This suggests that stress occurs in a different part of the joint. Where the joint surfaces make contact depends on the force, size, and position of the load. The load pattern changes from normal when injury occurs.

The authors conclude that CT osteoabsorptiometry can be used as a tool to measure and monitor joints. It shows the stress pattern and load of unstable joints by using mineral content of the bone. Differences in joint shape don’t seem to affect the contact area or load pattern. This information may help doctors and surgeons choose the best treatment option for each patient.

When the shoulder gets stuck and just won’t move properly, it’s called a “frozen shoulder.” The medical term for this condition is adhesive capsulitis. Treatment with drugs and exercise doesn’t always work. In such cases the doctor may advise a joint manipulation under anesthesia.

This type of manipulation has some problems, though. There is a chance of damaging the soft tissues in and around the shoulder joint. A new way to do manipulation for adhesive capsulitis is proposed by the author of this study. The new method is called translational manipulation (TM).

This report carefully reviews both the old and the new methods. How, when, and why to do TM is covered in detail. Hand placement and forces involved in the treatment are also discussed.

The authors describe when and why to repeat the technique in some cases. Doctors performing this treatment are given key points to remember for a successful manipulation. A single case study involving a woman in a car accident is presented. Her case showed how TM can be used when other areas of the joint are also hurt. Unless it’s done right, TM could cause more harm than good in such cases.

According to this report, TM is safe and effective. Its results are reproducible. This means another skilled manipulator can use this method with the same good results. The key to a successful manipulation without causing further damage to the soft tissues of the joint is to control the forces through the joint. When TM fails, the authors advise combining arthroscopic release with manipulation.

A study to find out what each part of the serratus anterior (SA) muscle does may help therapists rehabilitate weak or injured patients. The SA starts at the shoulder blade and wraps around the side of the rib cage.

Physical therapists from five different clinics worked together to test 29 healthy adults. Electrodes were used to record electrical activity of the SA in several test positions. Each muscle test was done three times. Subjects rested 30 seconds between each set of exercises.

The researchers found that the upper part of the SA works to move the shoulder blade away from the spine. This movement is called protraction. The lower part of the SA rotates the shoulder blade upward. In this report, they describe each muscle test and what SA activity was found with each one.

Based on these findings, the researchers make a few suggestions for therapists working with patients to strengthen the SA. First, there was a lot of variability from subject to subject. No one muscle test will work for everyone.

Second, the push-up plus exercise is a good one to strengthen the SA. This is done in the push-up position with the patient protracting the shoulder blade as much as possible.

Third, the result of this study may help therapists choose the right test and design the optimal exercise program for each patient’s SA muscle.

The results of this study will help doctors diagnose shoulder problems. Many patients with shoulder pain really have a problem with the acromioclavicular (AC) joint. The AC joint is where the outer edge of the collarbone (the clavicle) meets the acromion. The acromion is a bony projection off the shoulder blade. It forms a roof or shelf over the shoulder joint.

Researchers at the Sports Medicine and Shoulder Service in Sydney, Australia, carried out 20 tests on patients with shoulder pain. Muscles were examined, and X-rays and other imaging studies were done. Range of motion was measured, and some special tests just for AC problems were done.

Then each patient had a steroid injection with a numbing agent into the AC joint. Patients who got more than 50 percent relief from pain had a true AC joint problem. The researchers compared the results of the tests with the results from the successful injections.

They found that two tests were very accurate when used together. The Paxinos test and a positive bone scan gave the best information. The Paxinos test is done by applying front-to-back pressure through the AC joint. If these tests are both positive, then there’s a 99 percent chance the patient has an AC joint problem.

A pain diagram is also a good screening tool for AC joint pain. The most common pattern with AC joint pain starts in the middle of the clavicle and goes out over the shoulder to the middle of the upper arm. The authors suggest more testing is needed if one test is positive and one is negative.