News Category: Shoulder

When a patient presents with symptoms of arm pain, cold limb, swelling in the arm, and/or tenderness in the armpit or above the collar bone, the physician may suspect one of several problems. Sorting through all the symptoms, the patient’s history, and conducting a physical exam may help rule out (or rule in) various possible causes. This result of this process (and even the process itself) is called the differential diagnosis.

One of the main causes of symptoms like this is called thoracic outlet syndrome (TOS). Thoracic outlet syndrome (TOS) can cause pain and numbness in the shoulder, arm, and hand. But testing for TOS is difficult. There is no one test to accurately diagnose TOS, and other conditions can have similar symptoms. Patients may need to go through several tests to find out if TOS is actually the cause of the pain. Making the right diagnosis often takes time and can be a cause of frustration, both for the patient and for the doctor.

That’s why Dr. Richard M. Braun an orthopedic surgeon from San Diego, California wrote this guide to the diagnosis of TOS for other physicians. By reviewing the typical history and clinical presentation (patient’s signs and symptoms), the physician is better able to decide what imaging studies or other diagnostic tests are needed. Understanding the cause of the problem is also important.

The main cause of TOS is that the nerves and blood vessels going to the arm and hand get squeezed near the thoracic outlet. The thoracic outlet is this opening between the scalene (neck) muscles and the rib cage. The nerves and blood vessels then go under the collarbone (also known as the clavicle), through the armpit (the axilla), and down the arm to the hand.

Thoracic outlet syndrome can occur for many reasons. For example, pressure on nerves and vessels can happen in anyone who has fractured the clavicle. It can also happen in people who have an extra first rib, although this doesn’t always result in TOS.

Extra muscle or scar tissues in the scalene muscles can put extra pressure on the nerves and arteries. Heavy lifting and carrying can bulk up the scalenus muscles to the point where the nerve and arteries get squeezed. Traumatic injury from a car accident can also cause problems that lead to TOS. In an accident, the shoulder harness of the seat belt can strain or tear the muscles. As they heal, scar tissue can build up, putting pressure on the nerves and blood vessels at the thoracic outlet.

Neck and arm positions used at work and home may contribute to TOS. People who have to hold their neck and shoulders in awkward alignment sometimes develop TOS symptoms. TOS symptoms are also reported by people who tilt the head and neck repeatedly or who have to hold their arms up or out for long periods of time.

That all sounds so easy and straightforward but in fact, the symptoms can be very confusing. This is especially true when more than one anatomical structure is being compressed (e.g., nerves and blood vessels). Surgeons rely on X-rays, MRIs, arteriography and venography (studies of blood vessels), and Doppler studies (tests of blood circulation) to provide additional helpful and diagnostic information.

Circulation problems can also be seen when certain tests are applied. The patient is put in positions that provoke or produce blood loss such as lifting the arms overhead. They hold the position for three minutes and the examiner monitors whether symptoms are aggravated by this approach and how quickly blood supply returns to the arm and hands.

Other tests that can be ordered include electrodiagnostic tests (nerve conduction velocity, electromyography or EMG) and physiologic and functional capacity tests. Muscle blocks can also be done to prevent muscles (like the scalenes) from contracting fully. The injection weakens the scalene muscle enough that it can no longer pull the first rib up against the nerves and blood vessels passing through the thoracic outlet. Such a test helps identify overused muscles that might be a problem.

A special work simulation machine can be used after a muscle block to mimic the type of work patients are doing on-the-job. If the symptoms are reduced or even gone after the injection, then positions used at work are likely contributing to the problem.

The author concludes by suggesting that the examining physician gather all the data needed to identify the cause of symptoms typical of TOS first before doing anything else. This includes the history, results of the physical exam, and results of the additional studies ordered. Once the data is analyzed, it may be clear how the information falls into line and points to a specific diagnosis. An accurate and objective diagnosis is essential to improved treatment outcomes.

Having a shoulder that repeatedly dislocates can be a major problem — especially for overhead throwing athletes. The shoulder can be surgically repaired but that’s major surgery. Surgeons are working to find arthroscopic ways to accomplish the same long-term results provided by open surgery. In this report, surgeons from Italy present the long-term results of 43 shoulders treated with arthroscopic Bankart suture-anchor repair.

The study is important because until now the standard surgical procedure to repair forward (anterior) dislocating shoulder has been an open Bankart repair. The Bankart procedure is done to reattach the labrum (a rim of fibrous cartilage) when it is torn away from the shoulder socket. When the force of injury is enough to tear the labrum, a piece of bone attached to the labrum comes with it. The layers of soft tissue around the labrum (ligaments, joint capsule, tendons) are also damaged and must be stitched back together layer by layer.

Chronic, recurring shoulder dislocations mean the shoulder is unstable. In other words, the shoulder joint is too loose and is able to slide around too much in the socket. If not treated, instability can lead to arthritis of the shoulder joint.

One of the questions the surgeons who conducted this study asked was, Will patients treated arthroscopically have arthritis later? They also wanted to know if shoulder function improved with the surgery and if the patients would be satisfied with the results. The final question was whether or not they could predict who might have a good (or poor) response to the arthroscopic Bankart repair using suture-anchors. Suture-anchors are stitches that reattach the labrum back onto the bone.

Here are a few details to give you an idea of just who these patients were. Most were men (only four women in the study). All but two were competitive athletes in contact or overhead sports. Everyone had at least one dislocation after the first injury. Some patients had as many as 10 more dislocations. Surgery to perform the Bankart procedure was done by the same surgeon in all patients included in the study.

The surgeon carefully described the procedure including patient position, type of anesthesia used (including an interscalene block), and portals used to insert the scope into the joint. Step-by-step surgical technique was outlined. Placement of each suture-anchor was also described.

As with most Bankart repair procedures, the postoperative management is as important as the surgical procedure. The healing area must be protected but without causing a frozen shoulder from lack of movement. For this reason, patients are placed in a sling with the shoulder slightly abducted (away from the body). The sling is worn for four weeks.

Elbow and wrist movements are allowed. Special shoulder exercises called Pendulum or Codman exercises are done everyday. These exercises are designed to keep the shoulder joint moving smoothly without stressing the repair. In this study, patients were progressed to passive shoulder motion two weeks after surgery. Passive motion means that someone else moves the shoulder for them. No shoulder muscle contraction is allowed — again, this prevents any stress on the healing tissue.

Sometime between six and eight weeks, patients were allowed to move from passive to active motion (moving on their own without help). At three months post-op, they started strengthening exercises for the rotator cuff (muscles around the shoulder). By the end of five months, most patients had returned to their full sports activity.

How did this group do with the arthroscopic Bankart repair? Well, the problem of recurrent shoulder dislocation wasn’t eliminated. A fair number of patients (16 per cent) had redislocation spontaneously (meaning without trauma). Adding in those who dislocated again due to trauma, there was an overall recurrent rate of 22.5 per cent (that’s almost one-fourth of the entire group).

The surgeons tried to tell if there was some specific reason why these athletes were still dislocating after surgical repair. It didn’t appear to be related to their age or the number of times they dislocated before surgery. Certainly, overhead throwing athletes had the greatest number of problems. Not having enough shoulder external (outward) rotation seemed to be a factor for some of the patients.

What about arthritis? Did these patients develop degenerative changes in the joint despite the surgery? Some did but the majority (two-thirds) did not have any signs of arthritic changes on X-ray. Those who did have changes were mild to moderate. There were no cases of severe degenerative arthritis — at least not at the end of the first 10 years.

And were the patients happy with the results? Eighty-four per cent (84%) said, Yes, they would have the same surgery over again. Most of them based this response on the fact that they could return to their previous level of sports participation. Those who were not satisfied with the results had recurrent dislocation(s) and/or experienced what is referred to as apprehension — feeling like the shoulder is going to dislocate with certain movements (external rotation, overhead throwing).

In summary, the authors note that arthroscopic stabilization does have acceptable long-term results when used to do a Bankart repair on unstable shoulders. Shoulder osteoarthritis isn’t really a big concern in the first 10 years after surgery. This group of patients will continue to be followed to see what happens over the next 10 years. Surgeons expect continued good results as surgical techniques improve over time.

Many adults (mostly women) between the ages of 40 and 60 years of age develop a strange case of shoulder pain and stiffness called adhesive capsulitis. You may be more familiar with the term frozen shoulder to describe this condition. But as we find out in this review article on the problem, frozen shoulder and adhesive capsulitis are actually two separate conditions.

What separates these two diagnoses? Both show up looking like a painful, stiff shoulder. But adhesive capsulitis (as its name implies) affects the fibrous ligaments that surround the shoulder and form what’s called the capsule. The condition referred to as a frozen shoulder usually doesn’t involve the capsule.

The terms frozen shoulder and adhesive capsulitis are often used interchangeably. In other words, the two terms describe the same painful, stiff condition of the shoulder no matter what causes it. A more accurate way to look at this is to refer to true adhesive capsulitis (affecting the joint capsule) as a primary adhesive capsulitis.

Secondary adhesive capsulitis (or true frozen shoulder) might have some joint capsule changes but the shoulder stiffness is really coming from something outside the joint. Some of the conditions associated with secondary adhesive capsulitis include rotator cuff tears, biceps tendinitis, and arthritis.

How does the orthopedic surgeon diagnose one from the other? An accurate diagnosis is made when an arthroscopic exam is done. Tissue samples taken from inside and around the joint are examined under a microscope. Four separate stages of primary adhesive capsulitis have been recognized from tissue sampling.

In the first stage, pain prevents full active shoulder motion (patient moves his or her own shoulder) but full passive motion (examiner moves shoulder without help from the patient) is still available. There are some inflammatory changes in the synovium but the capsular tissue is still normal.

In stage two (the freezing stage), pain is now accompanied by stiffness and the patient starts to lose full passive shoulder motion. External rotation is affected first. The rotator cuff remains strong. These two symptoms differ from secondary adhesive capsulitis (what might otherwise be called a frozen shoulder). The condition referred to as a frozen shoulder is more often characterized by damage to the rotator cuff and loss of internal rotation first. The pain during stage two is worse at night. Cellular changes continue to progress with increased blood flow to the synovium. There are early signs of scarring of the capsule from the inflammatory and repair processes.

By stage three of primary adhesive capsulitis (the frozen stage), there is less pain (mostly at the end range of motion) but more stiffness. There is a true loss of active and passive shoulder joint motion. Very little if any inflammation is seen in the tissue samples viewed under a microscope. Instead, the pathologist sees much more fibrotic, scar tissue.

In the final (chronic) stage (stage four) the patient doesn’t have pain but profound stiffness and significant loss of motion that is gradually starting to get better. The body is no longer attempting to repair or correct the problem. Enough scar tissue is present to make it difficult for the surgeon to see the joint during arthroscopic examination.

Treatment is based on any underlying causes (if known), any risk factors present, and the stage at the time of diagnosis. Some of the risk factors for adhesive capsulitis include diabetes, thyroid dysfunction, and autoimmune diseases. Anyone who has had a heart attack, stroke, or been treated for breast cancer is also at increased risk for this condition. But a significant number of people develop adhesive capsulitis without any known trauma, medical history, or other risk factor.

There isn’t a one-best-treatment known for adhesive capsulitis. The authors point out that studies done so far just haven’t been able to come to a single evidence-based set of treatment guidelines for this problem. So, they offer their “preferred” method with the caution that although this set of steps seems to work for them, no studies have been done to prove the validity of their approach.

Having said that, they recommend using a cortisone injection into the joint only during stage one. The steroid helps stop the inflammatory process that often gets out of hand if left untreated. They don’t recommend the use of oral (pills taken by mouth) steroids but oral nonsteroidal antiinflammatories (NSAIDs) are given throughout all stages.

Physical therapy is the mainstay of nonoperative treatment during all stages. The therapist decides what approach to take based on the stage of disease. Early on, the goal is to reduce pain and interrupt the inflammatory cycle. This can be done with modalities such as electrical stimulation, joint mobilization, the use of cold, and iontophoresis. Iontophoresis is a way to push medications through the skin directly into the inflamed tissue.

During stage two, the therapist will address the capsular tightness and adhesions. Joint mobilization techniques are used to keep the joint sliding and gliding smoothly and to prevent scar tissue from forming. Keeping full shoulder and scapular (shoulder blade) motion is a priority. Special stretching techniques are used to prevent pain that could cause muscles around the shoulder to tighten even more.

Physical therapy throughout stages three and four continues in a similar fashion with added strengthening exercises. If conservative care fails to relieve pain and stiffness, then arthroscopic surgery is considered as the next step. The surgeon cuts the capsule, releases adhesions, and manipulates the shoulder (moves the arm through its full motion) under anesthesia. Physical therapy resumes immediately (the next day) after surgery.

No one knows really what happens with adhesive capsulitis that goes untreated. This is referred to as the natural history. Most patients eventually make their way to the physician’s office or a physical therapy clinic and receive some kind of medical treatment or hands-on therapy. There are enough cases of people who just get better on their own over time to suggest treatment may not be needed or make any real difference. Such cases are said to be self-limiting.

The few studies that have been done to follow patients treated at home without therapy by using moist heat and oral antiinflammatory medications report normal function. They were asked to fill out questionnaires several years later with information on current pain and function. Some of those patients still had mild pain. In one study, “normal function” was according to the patient — no formal strength testing was done. In other studies, this type of self-assessment wasn’t accurate. Tests of shoulder motion and strength showed unreported (unrecognized?) limitations in strength and motion.

In summary, the authors present a clear description of true adhesive capsulitis. They provide a detailed description of their preferred treatment based on four stages of disease identified arthroscopically. A review of the studies available has not provided a best-practice way to treat this condition. Future studies are needed to compare different treatment techniques against one another and in comparison with no treatment.

Ever hear the slogan, Air is our enemy? Back when ziplock plastic bags were first used, the modern homemaker knew the reason these “baggies” were so helpful in the kitchen — they reduced the amount of air around the food keeping it fresher longer.

There are other times in life when air is our enemy. Take for example, arthroscopic surgery of the joint. Even a small bubble of air introduced into the joint can travel to the heart or brain and cause sudden death. That air bubble is referred to as a venous air embolism. Embolism is another word for an object (e.g., air, blood, fat) that travels through the bloodstream, lodges in a blood vessel, and blocks it.

When performing arthroscopic surgery on the joint, it is necessary for the surgeon to put something inside the knee to distend or expand it. Over the years, different substances have been used — first nitrous oxide (laughing gas), then carbon dioxide. But studies showed that the use of any gas could result in a deadly embolism. Now surgeons use water or saline (salt solution).

But guess what? Cases of sudden death have occurred even when using an all-liquid arthroscopic system. It’s rare but it’s still fatal and therefore unacceptable. That’s what sent the authors of this study back to the lab to try and figure out what’s going on.

They started with the hypothesis (theory) that somehow even with an all-liquid arthroscopic procedure, air was getting into the joint. Where was it coming from? Was it an error in the way the procedure was being done? Was it the type of arthroscopic unit used? Maybe it was coming from a particular brand of saline solution bag.

So three surgeons from three separate institutions (a university hospital, a general hospital, and a surgery center) carried out this experiment. Each one tested three different types of arthroscopic pumps. Two different brands of saline solution were used.

They carefully inspected each bag for any signs of air. By turning the bags upside down and inserting a syringe, they were able to draw out of the bag any gas or air and measure it. The goal was to find out if it is possible for the arthroscopic pump to pull air from the bags of saline and then pump it through the system.

They were able to design the experiment in such a way as to be able to measure how much air was introduced into the system. They also devised a way to prevent air from entering the closed-system arthroscopic pump and tested it as well.

Sure enough (as suspected), they found that air in the saline-solution bags can be the source of venous air embolism in arthroscopic surgery. Not only that, but even a tiny amount of air is enough to cause a fatal result. And even though it seems like a rare event (there are only a few cases reported now and then), the authors suspect venous air embolism during shoulder arthroscopy happens more often than is realized or reported.

They concluded that by taking all of the gas out of the saline bags before connecting them to the arthroscopic pump takes care of the problem. It’s a simple thing to do before getting started. It can be done with a sterile technique. And best of all, it’s 100 per cent effective as proven by this experiment. With the two different brands of solution tested, there was a big difference in how much air was in the bags. Surgeons will want to pay attention to this important detail.

One other recommendation was made as a result of this experiment. The tubing attaching the bag of saline-solution to the pump must be free of air, too. This is an important step when one bag runs out and it’s time to use another bag. In some surgeries, two or three bags of saline-solution are used. Each time the bag is changed, not only must the bag be bled of any air but the tube must be primed to eliminate any air as well.

Rotator cuff tears are a common cause of shoulder pain, stiffness, weakness, and loss of motion and function. Treatment starts with conservative (nonoperative) care in physical therapy and/or with steroid injections. But in some cases, conservative care fails to reduce the painful symptoms or restore normal motion. That’s when surgery may be needed.

The rotator cuff is a group of four muscles with their tendons that surround the shoulder joint giving it both strength and stability. Without an intact rotator cuff, the shoulder can dislocate or may be so weak the person can no longer lift the arm up overhead or reach out to the side. Surgery to repair the damage is usually successful.

But what happens if conservative care fails and surgery fails? What are your options then? Dr. Ryan T. Bicknell, an orthopedic surgeon from Queen’s University in Ontario, Canada presents seven different treatment approaches for the failed rotator cuff repair. These patients continue to have pain, stiffness, weakness, and loss of function despite having surgery to repair the damaged tendons.

Just as before, conservative care is the first line of treatment. It is still possible that a program of strengthening exercises combined with postural changes can bring about the changes patients are looking for. But if a three-month trial of physical therapy and home program doesn’t solve the problem, then the patient is probably looking at a second surgery.

The surgeon will evaluate each patient in order to determine the most appropriate next step. It could be something as simple as a re-repair. The surgeon goes back in and resutures the torn tendon, stitiching the tear closed. This option isn’t usually possible because of poor tendon integrity, too many torn tendons, or too much fat replacing collagen (tendon) tissue.

Sometimes it’s just a matter of going in and cleaning up frayed edges of tendon. This procedure is called debridement. At the same time, the surgeon may address lesions of the long head of the biceps tendon. Damage to the biceps (muscle that bends the elbow) is often associated with massive rotator cuff tears and may be responsible for chronic shoulder pain and dysfunction. The surgical procedure for biceps repair is called a biceps tenotomy or tenodesis.

The real key to determining what to do next depends on what is causing the persistent shoulder pain and symptoms. For example, without a normal healthy rotator cuff doing its job, the head of the humerus starts to move up putting pressure on the suprascapular nerve. Relieving tension on the nerve may reduce painful symptoms.

Some patients have massive tears that just can’t be repaired. In such cases, the age of the patient may dictate the treatment. In younger patients, the surgeon can take another tendon nearby and transfer it to do the work of the torn rotator cuff. In older adults, a hemiarthroplasty or reverse shoulder arthroplasty are better choices.

Both of these procedures are a type of shoulder replacement. The hemiarthroplasty just replaces one side of the shoulder (usually the round head and attached neck of the humerus, the upper arm bone).

A reverse shoulder arthroplasty is a total shoulder joint replacement with a twist. Instead of the round head at the top of the humerus, the surgeon inserts a socket-shaped implant. The round portion fits where the natural socket used to be. This type of replacement surgery works well when the rotator cuff is so severely damaged it no longer functions to stabilize the joint.

Results using these different approaches to the failed rotator cuff surgery are varied. Reports from studies indicate problems with continued pain, inability to raise the arm, and disapointed or dissatisfied patients. Overall, the results are better than without surgery but they aren’t close enough to “normal” to satisfy the customer. The type of motion that is lost (lifting the arm overhead and externally rotating the shoulder) results in significant problems with function.

The author concludes that in treating massive rotator cuff tears, all efforts should be made to attain good results with conservative care first and then rotator cuff repair. If the first surgery fails to do the job, a second procedure may be needed. Revision surgeries are often less than successful with high rates of complications. Patients should be warned of possible problems and prepared for the fact that the surgery may not be as successful as they would like.

Many studies have been done in gaining understanding of shoulder dislocations. For example, surgeons have asked the question: can they get better without surgery? If surgery is done, will arthritis set in sooner than if there never had been an injury? Another area of investigation has been the role of surgery as the cause of arthritis after repeated anterior (forward) shoulder dislocation.

In this study, a different approach was taken. This time, the presence of osteoarthritis in the shoulder joint before surgery was examined as a possible factor in the development and progression of shoulder osteoarthritis. Patients in this study were young athletes who had a shoulder injury that resulted in recurrent dislocations. All patients included had surgery to restore shoulder stability using the Bankart procedure.

The Bankart procedure is done to reattach the labrum (a rim of fibrous cartilage) when it is torn away from the shoulder socket. When the force of injury is enough to tear the labrum, a piece of bone attached to the labrum comes with it. The layers of soft tissue around the labrum (ligaments, joint capsule, tendons) are also damaged and must be stitched back together layer by layer.

In order to find the answer to the question of whether osteoarthritis was present before surgery was ever done, preoperative X-rays and CT scans were done. The surgeon also inspected the joint after making an open incision to see the damage but before making the repair. While gathering data for about the patients, the authors also analyzed the role of other factors on the development of arthritis such as age, gender, total number of dislocations, and side affected.

One-fourth of the patients had early (mild) arthritic changes observed in the shoulder before surgery. Only seven per cent of those cases actually showed up on X-rays. That’s because the most frequent sign of early arthritis was bone spurs developing where the labrum attaches to the shoulder socket. This type of change doesn’t appear on X-rays until the spur formation is much more advanced. The surgeons confirmed these changes when looking at the joint during the Bankart procedure.

After following these patients for five to 20 years, they saw that the arthritis progressed slowly over time. In some cases, the arthritic changes were never seen on the radiographs (X-rays). Patients who had the most severe bone defects had a higher rate and more severe arthritic changes. They were also more likely to experience repeated dislocations compared with patients who had no bone damage.

The authors conclude that CT scans may be helpful in the diagnosis of osteoarthritis in recurrent anterior shoulder dislocations. Severity of bone defect leading to preoperative arthritis can be identified using CT scans instead of standard X-rays.

Early arthritis does not seem to be linked with the age of the patient at the time of injury or the length of time between injury and surgery. The more often the shoulder dislocates, the more likely postoperative arthritic changes will develop. These preoperative dislocations cause repeated trauma to the shoulder and worsening instability.

Instability of this type should be treated operatively to avoid the worsening of arthritic changes. Whether or not the Bankart procedure itself is a factor in the development of postoperative arthritis should be studied more in the future.

One of the most common orthopedic procedures performed in the United States is an acromioplasty. In fact, according to this report, in the last 10 years, the number of acromioplasties done in the U.S. has increased by more than 250 per cent. The study was done in New York where there were 5,571 acromioplasties done in 1996 and 19,743 in 2006.

What’s an acromioplasty? It’s the removal of a small piece of bone called the acromion. The acromion comes from the scapula (shoulder blade at the back of the shoulder) across the top of the shoulder to connect with the clavicle collar bone in the front of the shoulder.

Why is it removed? Generally, removal of the acromion is done to take pressure off the rotator cuff tendons as they pass under the acromion to attach to the upper arm. Until recently, it was believed that the reason these tendons got frayed or damaged was from rubbing against the bottom of the acromion. Shaving the underside of the acromion or removing the end of the bone altogether is one way to deal with the problem.

Rotator cuff degeneration seems to be common in midlife, often occurring between the ages 30 to 40 years old. Mechanical impingement (pinching) from the acromion was considered the major cause of this problem. So it seemed logical that to remove the acromion would solve the problem.

As a result, the acromioplasty procedure, first used in the early 1970s has gained in popularity since then. But better technology with the use of magnetic resonance imaging (MRI) and arthroscopic examination has revealed some new information to consider. And that is the fact that mechanical impingement isn’t the only problem causing rotator cuff degeneration.

It seems that changes are taking place within the rotator cuff tendons that may have nothing to do with rubbing against the acromion. And studies showing the outcomes after acromioplasty have not been that positive. It’s starting to look like conservative (nonoperative) care may yield just as good of results as surgery with good pain control and improved function.

If that’s the case, then the use of acromioplasties for rotator cuff problems should be re-evaluated more carefully. At least that’s the conclusion of this report. The authors used medical records and orthopedic physician board certification reports just within the state of New York. But a review of data collected by the American Board of Orthopaedic Surgery (ABOS) showed a similar increase on a national level.

Analysis of the data collected in this study also showed an expansion of the types of patients treated with an acromioplasty. In 1996, most of the 5,571 patients had a diagnosis of impingement syndrome. By 2006, there were many more cases of sprains and strains of the rotator cuff, shoulder bursitis, labral tears, and rotator cuff ruptures.

Acromioplasties were done 2.4 times more often compared with other orthopedic procedures for ambulatory outpatients (able to walk in and leave the same day). The expansion of diagnostic reasons for using this operation might explain that increase.

Other reasons included better surgical techniques, improved technology, and more advanced surgeon training in medical schools (especially in the area of shoulder surgery). Patient preference may be a bigger factor than we realize. It’s possible that patients don’t want to spend six weeks to six months in rehab and opt for the faster surgical approach.

In conclusion, it’s clear that the number of acromioplasty procedures being done in the United States each year has increased dramatically. The reasons for this are many and varied but may be justified. This is the first study to bring the increased utilization of acromioplasties into focus. Further evaluation of the need for so many acromioplasties will be the topic of future studies.

An orthopedic surgeon from West Point has proposed a new classification for shoulder injury called the transient luxation. Based on a study of over 4,000 military cadets, this problem was identified in 38 students.

What is transient luxation? It’s somewhere between a shoulder dislocation and subluxation (partial dislocation). The force of the injury was enough to cause a separation of the joint. But because the shoulder went back into place, it doesn’t count as a complete dislocation. MRIs taken within two weeks of the injury showed damage to the surrounding tissues. The imaging studies were enough to show there was more than the disruption of a subluxation.

Transient luxation is diagnosed when a traumatic event causes a shoulder dislocation that is accompanied by either a Bankart lesion or a Hills-Sachs lesion. The Bankart lesion is a tear in the labrum (rim of fibrous cartilage around the shoulder joint). The labrum gives the shallow shoulder socket a bit of extra depth. It helps stabilize (hold) the shoulder in the socket.

The Hill-Sachs lesion refers to a dent in the head of the humerus (upper arm bone). When the shoulder subluxes or dislocates and then goes back into the socket, the smooth cartilage surface of the humeral head hits against the shallow socket causing this dent. Seeing the dent on X-ray tells the surgeon that the shoulder was disrupted enough to pop out of the socket and then shift back in.

This is the first study published reporting on first-time, acute shoulder injuries resulting in transient luxations. Most of the time, research is done on athletes who have a full dislocation or chronic, recurrent subluxations. But this is the first to look at the changes that occur within the joint when a first-time subluxation occurs that does not require manual or surgical reduction (putting the shoulder back in the socket).

Using X-rays and MRIs, the surgeons were able to show clear evidence of pathologic changes in the joints of these cadets. The head of the humerus was pulled away from the socket with enough force to completely separate the two joint surfaces, a process called luxation.

Because these injuries normally spontaneously reduce (head of the humerus goes back into the socket by itself), X-rays and MRIs aren’t routinely taken. Having this information at the time of diagnosis helps plan treatment. Since there is a high rate of recurrence (a second) subluxation, knowing there is additional damage to the joint helps guide treatment.

Treatment is with physical therapy to try and rehabilitate the shoulder and restore joint stability. If recovery is not possible, then surgery is the next step. To give you some idea of how many patients recover without surgery, how many develop recurrent instability, and how many end up having surgery, here are a few statistics from this study.

There were 27 of the 38 cadets who had the necessary imaging studies done within two weeks of injury to qualify for this study. Most had both a Bankart and a Hill-Sachs lesion. About half (13 of the 27) opted for the conservative (nonsurgical) approach. Four of those 13 ended up having recurrent subluxations and required surgery. Follow-up was only for a year but at that time, the students who had surgery remained on active duty without any further shoulder problems.

Although this study was done in the military at West Point, the type of patients involved represent many athletes who sustain a similar shoulder subluxation (transient luxation) injury. Most of the injuries in this study were the result of missed punches (boxing), tackles (football or soccer), and falls (obstacle course). Only one injury was directly related to military training.

The authors concluded that diagnosing certain shoulder injuries as either a subluxation or dislocation doesn’t tell the whole story. For some athletes, there has been a complete dislocation that has spontaneously reduced and appears as a subluxation. Imaging studies show enough disruption and damage to the joint and surrounding tissue to suggest a third (in-between) classification referred to as transient luxation.

The results of this study support the need for MRIs even with subluxations that reduce themselves. Management of the problem depends on knowing the extent of damage. Surgery may be needed to prevent recurrent subluxation and restore joint stability.

A snapping or catching sensation felt along the front of the shoulder can be caused by many different problems. There could be a torn rotator cuff or a torn labrum. The labrum is a fibrous rim of extra cartilage around the otherwise shallow shoulder socket. It helps give the shoulder socket more depth and keeps the round ball at the top of the humerus (upper arm bone) in the socket.

Other possible causes of shoulder snapping include bursitis, tendon tears, bone spurs, or loose pieces of cartilage or bone inside the shoulder joint. In this case report, the authors describe the symptoms, diagnosis, and treatment of shoulder snapping in a 23-year-old weight lifter.

When the weight lifter first went to the Mayo Clinic Sports Medicine Center in Rochester, Minnesota, he had an eight-week history of painful shoulder snapping. The snapping occurred whenever he lifted his arm straight forward with the elbow straight or when he used his left arm in a rowing motion. Both of these movements are important in weight lifting activities, so it wasn’t something he could ignore for long.

When he was examined, the shoulder was stable with no sign of a rotator cuff tear. There were no other disturbing symptoms like numbness, tingling, swelling, or weakness. Rest and activity modification did not alter the symptoms so X-rays and ultrasound imaging tests were ordered.

The imaging studies showed a pocket of fluid over the tendon of the subscapularis muscle. The subscapularis muscle is part of the rotator cuff, so although the rotator cuff wasn’t torn or ruptured, there was evidence of a tendinopathy. Tendinopathy refers to chronic changes in the tendon without active inflammation.

Inflamed tissue was observed around the subcoracoid bursa. The subcoracoid bursa is sandwiched between the subscapularis muscle and the coracoid process. The coracoid process is a hook-shaped piece of bone that comes from the shoulder blade to help stabilize the shoulder. This subcoracoid bursa is separate from the subscapularis bursa.

The subscapularis bursa actually drapes itself over the top of the subscapularis tendon rather than between the subscapularis tendon and nearby bones. The difference in location of these two bursae is seen on imaging studies and helps clearly identify the exact cause of the problem.

Treatment for a chronically inflamed bursa (bursopathy) can be conservative (nonoperative), a steroid injection (invasive but still nonoperative), or surgery. This particular patient chose surgery, which involved removing the affected bursa. He had a short (four-week) postop rehab program and returned to weight lifting three months later. The surgeon called this a rare case of subcoracoid bursitis causing painful shoulder snapping.

The subcoracoid bursa is designed to allow for smooth sliding and gliding of the humeral head as it rotates inside the shoulder socket. The primary function of this bursa is to allow smooth, pain free shoulder rotation.

It’s likely that the weight lifting activities involving overhead shoulder lifts led to a subcoracoid impingement (pinching). The head of the humerus presses up against the soft tissues that form an arch above the humeral head. Any number of things can narrow the space under the arch. In the case of a serious weight lifter, the muscles around the area bulk up, thus decreasing the space available for the bursa.

The symptoms in this case were not the same for a typical case of subcoracoid impingement. That’s why some of the standard tests (e.g., Gerber test, Yokum test) weren’t positive. The repetitive weight lifting exercises built up certain shoulder muscles that altered the way the tendons shifted during some shoulder movements.

The authors presented this patient case because it was a rare shoulder bursitis causing shoulder snapping in an otherwise healthy but athletic adult. Ultrasound imaging gave the best picture of what was going on to cause the problem.

Physicians are advised to consider the possibility of a subcoracoid bursitis as a possible diagnosis in cases of shoulder snapping among athletes, especially overhead weight lifters. The underlying cause could be one of several soft tissue changes contributing to pinching of the tendons and/or pinching of the bursa between the humeral head and the coracoid process.

Musculoskeletal injuries are common in the military. The physical training required to achieve a certain level of strength and endurance can contribute to soft tissue trauma. Information gained from military studies benefits orthopedic surgeons and sports medicine professionals working with young adults and athletes who have similar problems.

In this report, injuries to the pectoralis major muscle are reviewed. Mechanisms of injury, anatomy, diagnosis, and treatment are discussed in detail. The pectoralis muscle is the large muscle across the chest that is most active when doing push-ups or lifting weights.

It is a two-part muscle that attaches above to the clavicle (collar bone) and down the length of the sternum (breast bone). It also attaches by a fairly narrow tendon (thin compared to the muscle size) to the upper arm next to the tendon insertion of the biceps muscle.

Injuries severe enough to rupture the tendon attachment occur most often when the muscle is fully contracted and then slowly lengthens against a weight. This mechanism of injury describes the bench press — lifting overhead with arms out to the sides, elbows straight, and shoulders externally rotated.

Pectoralis major ruptures have also been reported as a result of work injuries. And this type of injury has been associated with a wide range of activities such as wrestling, sailing, water skiing, snow skiing, rugby and soccer, football, boxing, and even parachuting.

In younger adults, the injuries almost always occur in males between the ages of 20 and 40. Older adults might have this type of injury when they have to be helped by others when transferring from bed to chair and vice versa. Pressure under the arms against stiff, weak muscles while being lifted is enough to cause crush injuries and hematomas (pools of blood around or inside the muscle).

To help the reader understand the anatomy and function of this very large muscle, drawings were provided. The article includes a complete description of the muscle layers, blood supply, and nerve branches to each segment. There are differences among people, so not everyone has the exact same location of blood vessels and nerves.

However, no matter what the anatomical configuration, when the muscle is ruptured, it is clear to the examiner looking at the patient. First, the patient describes a pop or tearing sensation while bench pressing. There is pain right away and the arm gives way because it is suddenly too weak to hold up.

Early on after the injury, there is obvious swelling across the chest and/or under the armpit and bruising in the same areas. Touching or pressing the area is painful. Moving the arm is also painful. Unless the person has ruptured both pectoralis major muscles, there is an obvious difference in visual appearance when comparing the unhurt side with the involved side.

There may be a bulge on one side of the chest where the muscle has pulled away from the bone and bunched up. A common sign of pectoralis major rupture is the loss of the crease of skin in front of the arm pit. This area is called the axillary fold.

To confirm the diagnosis, it may be necessary to order X-rays, ultrasound studies, and/or MRIs. But most of the time, it is quite obvious what is the problem and further imaging studies aren’t needed. X-rays are often negative unless there has been a bone fracture at the same time or a piece of bone (avulsion) has pulled away with the tendon rupture.

Ultrasound can show damage to the muscle and the presence of hematomas. MRIs help the surgeon see exactly where the damage has occurred and if the tendon is partially or fully ruptured. The MRI also shows the current location of the tendon and how far back it has pulled away (retracted) from the bone.

Since the insertion of the pectoralis major tendon is so close to the biceps tendon, the MRI clears up any confusion about what is included in the damage. All of this information can help when deciding what type of treatment is best.

Most of the time, surgery is required to repair the damage. It’s during the operation that the surgeon gets a close up view and 100 per cent accuracy in the diagnosis. Only older adults are treated conservatively (nonoperative). With rest, support (arm in a sling), and the use of cold and later heat, these injuries can heal enough to allow the less active person to perform normal daily activities without pain.

In younger patients, whether the injury is fairly new (acute) or old (chronic), recovery is not likely without surgery. The tendon is returned to its normal position and reattached with sutures (stitches). There are several different ways to do this.

Some involve drilling holes in the bone, threading sutures or anchors through the holes and tissue to hold the tendon in place until it can reattach and accept tension during muscle contraction. The authors provide drawings, descriptions, and photos taken during the operation to explain the basic procedure.

Special problems are discussed such as the presence of scar tissue and adhesions in chronic injuries. When the tendon can’t be pulled back and put in its original place, graft (donor) tissue is used to restore the natural length of the tendon.

With the proper follow-up and rehabilitation, pectoralis major muscle ruptures treated surgically can bring about excellent results. Recovery ranges from six weeks to 24 months. Most patients are able to resume normal activities, military involvement, and sports participation at the end of a year (some as early as four months postoperatively).

For physicians who would like to learn more about this topic and/or participate in a continuing medical education program, there is an on-line course available. This one-credit course meets the standards of the Accreditation Council for Continuing Medical Education (ACCME). It is available at http://ajsm-cme.sagepub.com.

Shoulder surgery to repair a rotator cuff tear is designed to reduce pain, restore power (strength), and improve motion. Patients report that pain relief is by far the most important and best result of this procedure. Is it possible to know before surgery how much improvement in pain might be expected?

According to orthopedic surgeons from Seoul, Korea, it is possible to predict pain reduction after rotator cuff repair. And they say this is the first study of its kind! How is it done? A simple injection of a numbing agent called lidocaine is inserted into the subacromial space.

The subacromial space is the area just above the head of the humerus (upper arm bone) and below the acromion. The acromion is a curved piece of bone that comes around from the back of the shoulder blade over the humeral head.

Muscles of the rotator cuff pass underneath this arch of bone. As the arm lifts up, the damaged (torn) or weak rotator cuff can get pinched between the head of the humerus and the acromion. This condition is called impingement. It’s the pinching of the tendon that causes pain and loss of motion and function.

Injecting a numbing agent into this space would provide substantial pain relief when impingement is the real problem. The authors called this test the modified impingement test. It’s modified because instead of just assessing pain while the arm is lifted, there’s been the injection of lidocaine as well.

Patients rated their pain when lifting their arms overhead before and after the injection. They were rechecked a year later after complete recovery from shoulder surgery. Surgery was done to decompress the pinched tissue and repair the torn tendon in 153 patients. All patients included had a full-thickness rotator cuff tear. The tests used to see if pain levels and function had changed included the visual analog scale (VAS), the Constant score, and the Simple Shoulder Test.

The surgeons found a definite correlation between pain relief with the subacromial injection before surgery and pain relief after surgery. In other words, the modified impingement test could accurately predict how much pain relief patients can expect after a decompression procedure and rotator cuff repair. And the test was predictive no matter what size tear was present (small or large).

The size of the tear was used to guide rehab after surgery. Patients with small tears were able to take the arm out of the abduction brace earlier (after four weeks). This compares with five weeks of immobilization for patients with medium tears and six weeks for large tears. Likewise, patients with smaller tears were allowed to move the arm sooner than patients with large or massive tears.

The authors concluded that their modified impingement test is simple, safe, and easy to do. It provides a fairly accurate estimate of how much pain relief patients can expect with rotator cuff repair surgery. It’s not a good predictor of how much change in motion or function they might expect from before to after surgery. But since pain is the primary symptom of concern, knowing pain will be relieved may be enough to satisfy patients and help them when making the decision to have surgery.

The front page of a newspaper may have all the local and world news but for millions of sports fans, it’s the sports page that gets attention over breakfast or morning coffee. Wins, losses, records, and placement in the standings are carefully reviewed. Newspaper, television, and radio all report on the health and any injuries of key players.

During baseball season, major and minor league pitchers have a special place in the news. A shoulder or elbow injury (the two most common types of injuries in these players) can put a pitcher out of the game. The loss of a pitcher can put the team at a disadvantage that can affect the win/loss ratio for the entire season.

The fans are disappointed, the team is distressed, and the owners stand to lose money if the team doesn’t do well. That’s why the results of this study may be very important for baseball fans, team players, and owners alike. What was the study? Sports orthopedic surgeons investigated the effect of preseason shoulder strength on the risk of in-season throwing-related injuries.

After looking over what’s already known about shoulder (throwing or pitching) injuries, they decided to see if weak shoulder muscles during preseason are linked with in-season problems. To test their ideas out, they measured the shoulder range-of-motion of 144 baseball pitchers.

All measurements were taken before the season began for five years in a row (2001-2005). Then they compared strength data with in-season injuries to see if there was a link between the two. Baseball pitchers from both major and minor leagues were included. Anyone who had a previous shoulder injury requiring surgery was followed closely to see if having shoulder surgery once before resulted in more shoulder injuries later.

As it turns out, a history of shoulder surgery did not mean the pitcher was more likely to reinjure that arm. But preseason muscle weakness in any player does point to the potential for increased risk of in-play shoulder injuries. The shoulder muscles that were important included muscles of the rotator cuff that externally rotate the arm (the cocked-back position needed to throw the ball forward).

Only injuries that occurred during pitching were included in this study. Injuries were not counted if a player ran into someone else or hurt himself while running or by falling. Players were divided into three groups: 1) those who had no injury, 2) pitchers who had an injury that could be treated conservatively, and 3) injuries that required surgery.

They found that shoulder injuries requiring surgery were more likely to occur when muscles used to externally rotate the shoulder (cock the arm back to throw) were weak. An imbalance between internal and external rotator muscle strength (one group stronger or weaker than the other) was a red flag that weakness could lead to injury. This finding has been reported in many other studies as well.

Professional baseball pitchers also end up in surgery when the supraspinatus muscle is weak. The supraspinatus muscle is one of the four muscles of the rotator cuff. Its major function is to abduct the arm. Abduct means the arm moves away from the body.

It’s no surprise that pitchers who repeatedly throw the ball in an overhead motion suffer from shoulder and/or elbow injuries. The authors of this study are among many sports health care specialists who are trying to find ways to reduce those injuries and keep the players in the game.

Preseason strengthening of the rotator cuff and muscles of the elbow/forearm may be the answer. Strong muscles help reduce the force and load placed on the joints during overhead throwing activities. Since all players normally participate in a strengthening and conditioning program, the next task is to find out what type of preseason exercise works best. Identifying players with weakness is the first step towards targeting those pitchers who might be at increased risk for injury.

Before and after measurements of pain, motion, strength, and function are a good way to track which patients improve with surgery and rate the level of success or failure for each procedure. But there are over 30 different tests that can be done. All are not equal or reliable. So, to help surgeons decide which test to use and when to use it, this article reviews many of the commonly used before and after outcomes measures.

You may even recognize the names of some of these tests: the American Shoulder and Elbow Surgeons (ASES) shoulder outcome score, the Constant Shoulder Score, Disabilities of the Arm, Shoulder, and Hand (DASH), the Western Ontario Osteoarthritis of the Shoulder Index (WOOS).

The American Shoulder and Elbow Surgeons (ASES) test has been around for the last 15 years. It was developed by a committee with the hope of using it for research. The ASES can be used with all patients no matter what’s wrong with the shoulder. And it can be used for patients treated conservatively (nonoperatively) as well as for those who end up having surgery for their shoulder problem.

The ASES assesses pain, instability, and function (activities of daily living or ADLs). The one major disadvantage of this test is the level of difficulty in calculating the score. It is widely used in the U.S. and Europe and can be used for research and for a general idea of how the shoulder is doing.

The Constant score is used to measure before and after results from surgery, but it can be used with nonsurgical cases as well. It does measure pain, activities of daily living (ADLs), shoulder motion, and strength.

But the Constant score test has not been validated for all different kinds of shoulder problems. And there are problems with examiner bias when it comes to measuring strength and motion. So, for now, the authors of this article who reviewed all the tests don’t recommend using it until some of these issues have been ironed out.

Everyone agrees that the Disabilities of the Arm, Shoulder, and Hand (DASH) is a good measure of disability for the arm that can stand alone (i.e., other tests aren’t needed along with it). It’s a questionnaire patients take answering questions about symptoms and physical function.

It can be completed quickly, scored with moderate ease, and used with many different shoulder problems (e.g., arthritis, tendinitis, psoariatic arthritis, rotator cuff problems and repair, shoulder joint replacement). For general assessment and worker’s compensation claims, the DASH can’t be beat.

And finally, the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) is rated the best for assessing results of total shoulder replacement and treatment for arthritis of the shoulder. The patient answers 19 questions about symptoms (including pain), sport, recreation, work, lifestyle, and emotional function.

This test can be given in a variety of languages including English, Spanish, French, and German. The WOOS can even be used to measure before and after results following arthroscopic debridement (cleaning out) of the joint.

Other tests are available to test more specific results. For example, there is the Rotator Cuff Quality of Life and Western Ontario Rotator Cuff Index. For patients who have had surgery for rotator cuff disease, there are a few additional tests such as the Rowe Rating Sheet for Bankart Repair, the Western Ontario Rotator Cuff index (WORC), and the Wolfgang criteria.

And that’s just the short list. There are tests for disability, pain, instability, sports injuries, and even for patients who are on Worker’s Compensation. Some tests (e.g., ASES, UCLA, SANE) are quick and easy to complete. Tests that are user-friendly (or patient-friendly) are popular. The Disabilities of the Arm, Shoulder, and Hand (DASH) falls into this category.

Finding and using the best tool to assess results (called outcomes) can be a bit of a challenge. The user (surgeon, physical therapist, sports specialist, researcher) decides which one to use based on several factors such as type of shoulder-specific problem, intended use of the data collected (clinical versus research), and ease of use and scoring (quick and simple are preferred). Other influencing factors can include whether or not the patient is a Worker’s Compensation claim, whether surgery has been done to treat the problem, and how much information detail is desired.

After looking each test over and evaluating their validity and reliability, the authors make one final conclusion. And that is: to obtain the highest level of outcome assessment, a test of general health outcome should be done. Along with that, the clinician or researcher should also measure activity and administer a disease- or condition-specific questionnaire. Combined together these outcome measures will give a broad assessment of each patient.

Orthopedic surgeons continue to seek evidence to guide all aspects of patient care. In this document, the American Academy of Orthopaedic Surgeons (AAOS) offers 16 guidelines for clinical practice in the care of patients with shoulder osteoarthritis.

There is a wide range of issues related to shoulder arthritis. The fact that the shoulder joint can be replaced with a joint replacement (implant) has changed the way patients are treated. Younger patients with shoulder arthritis has helped push the envelop so-to-speak, meaning the search is on for the right treatment for all ages.

Every day surgeons around the world weigh the pros and cons for the treatment of their patients’ painful shoulder arthritis. Patient factors such as age, occupation, severity of symptoms, general health, and education level are taken into consideration when choosing a treatment path. The surgeon’s examination and X-ray findings also provide important information when forming the plan of care.

But everyone wants evidence that guides these clinical treatment decisions and that’s what this article provides. Well, the authors actually offer what they found by way of reviewing the published studies available. In the end, they come up with 16 recommendations but admit that nine of them are not based on solid evidence. Only two of the 16 recommendations could be agreed upon by all 15 panel members.

Let’s start with the two confirmed recommendations and then take a look at the major points for the remaining 14 guidelines. The consensus was that first, prevention of blood clots after shoulder arthroplasty (medical term for joint replacement) is a top priority. Prevention must take place using mechanical and/or chemical means. And second, patients who have a torn rotator cuff are not good candidates for shoulder replacement.

The remaining guidelines cover a variety of treatment options from drug management and physical therapy to steroid injections, viscosupplementation, and arthroscopy. Specific surgical techniques such as the use of a hemiarthroplasty (only one half of the joint is replaced) versus a total arthroplasty (both the humeral head and the cup or socket are replaced) are discussed. The following key points are offered:

When it comes to middle-aged adults with shoulder injuries, surgeons are sometimes left scratching their heads puzzled over what to do. Should a full-thickness (complete rupture) of the rotator cuff be repaired at the same time a SLAP lesion is present?

SLAP refers to the superior labral anterior-posterior structure around the shoulder joint. Superior anterior-posterior tells us the location of the damage: top of the shoulder socket from front to back. The structure that is torn is the labrum, a fibrous rim of cartilage around the shoulder socket. It is designed to help hold the round head of the humerus (upper arm bone) in the joint thus increasing the joint stability.

Another puzzling question is: what’s the best way to treat the SLAP lesion? Some studies have shown that surgical results vary depending on the age of the patients. For example, younger age groups (ages 18 to 40) tend to have poor outcomes when SLAP lesions are repaired at the same time as shoulder decompression is done. Decompression removes some of the bone that is pressing on soft tissues around the shoulder.

Older adults (over age 40) don’t seem to respond well to surgery for SLAP tears. They get stiff after the recovery period and lose function. Some research has been done to see if a staged procedure (doing the two repairs separately; first repair the rotator cuff, then later repair the SLAP lesion) might have better results.

In this study, surgeons from Harvard Medical School compared two groups of middle aged adults after surgery for shoulder injuries. The first group had a torn rotator cuff but the labrum was undamaged. The second group had both a rotator cuff tear and a labral tear (SLAP lesion). Surgery for the group with damage to both the rotator cuff and the labrum was done all at one time. This is referred to as a concomitant procedure.

There were 34 patients in the group having the concomitant procedure and 28 in the group just having a rotator cuff repair. All patients in both groups had minimal muscle atrophy (wasting) and minimal fatty infiltration (fat filling in the damaged area). Everyone had tried recovery with conservative (nonoperative) care but without success.

One surgeon operated on all patients in both groups. The postoperative care was the same for both groups. Everyone wore a sling with a special pillow under the arm to keep the shoulder positioned slightly away from the body. A physical therapist supervised an intensive rehabilitation program for all 62 patients.

To measure the results and compare outcomes from one group to the other, everyone was tested before and after surgery. The specific tests involved shoulder range-of-motion and function. Information was gathered about patients in both groups and used to analyze differences based on sex, age, type of injury, type of tear, work status, and involvement in sports.

Everyone got better after surgery no matter which procedure they had done. Range-of-motion and function improved significantly in both groups. Almost everyone in both groups was able to return to work and return to sports previously enjoyed. No one was unhappy with the results.

The authors concluded that it is both safe and effective to combine a SLAP repair with a rotator cuff repair in middle-aged adults. The fear that the shoulder will stiffen up too much just isn’t a reality. The need for a two-part (staged) procedure isn’t there either. The results for the combined (concomitant) surgical group were just as good as for those patients just having a rotator cuff repair. And the authors point out that the average age of patients in this study was 58 years old (older than has been reported in other studies).

There is also some evidence that the aggressive rehab program after surgery might account for the good results. It is possible that early motion is the key to preventing stiffness later. However, intense early range-of-motion programs come with the risk that the repaired soft tissues might re-tear. Future studies are needed to follow patients and perform postoperative imaging studies to see the effect of different types of rehab after surgery.

Have you ever wondered how some people can put their leg behind their head or use their clasped hands together like a jump rope? How can anyone move like that without dislocating a joint? Most likely those individuals have something they are born with called joint hyperlaxity. The condition is considered congenital because it is present from birth throughout life.

Joint hyperlaxity means the soft tissues around the joint that usually hold it in place are extra long and very elastic. Without those restraints, the joint can slide and glide all over the place. The end result is the ability to move and rotate joints in all directions without dislocation.

Can those joints be dislocated? Yes they can but it doesn’t happen very often. Shoulder instability in people with joint hyperlaxity is the subject of this report. Surgeons from the Shoulder Injury Clinic from England review the latest ideas about shoulder joint hyperlaxity.

They discuss what can happen to cause a hyperlax joint to become unstable, how surgeons can assess patients with this type of problem, and treatment for shoulder hyperlaxity with instability. Both nonoperative and surgical procedures are presented.

Shoulder hyperlaxity with instability is different from chronic shoulder instability from a traumatic dislocation. Usually, a shoulder that has dislocated does so in one direction (forward most often). This is called a unidirectional laxity. That’s the direction it will tend to dislocate again. Hyperlax joints have multidirectional laxity (excess motion in all directions not just one direction).

That is one major difference between traumatic versus hyperlax instability. Another is the fact that with a traumatic injury, there’s often damage to other soft tissue structures that help support the shoulder. With congenital hyperlaxity, there’s nothing wrong with the supporting soft tissue structures or the underlying bone.

There is actually a third group of people who fall into shoulder problems from hyperlaxity. That group is made up of athletes who use their shoulder(s) over and over and over causing the soft tissues to stretch out too much. Overuse or overtraining often only affects one direction of shoulder motion making this a problem of unilateral hyperlaxity.

What can be done about shoulder instability associated with joint hyperlaxity? Sometimes nothing needs to be done. The patient modifies or changes his or her activities to avoid problem motions or activities and all is well.

In other cases, it’s necessary to modify activities and see a physical therapist. The therapist can provide a program of exercises to help strengthen the muscles around the joint. Strong muscles help stabilize loose joints. The patient with multidirectional shoulder hyperlaxity must follow the prescribed program for at least one year with a maintenance program that should be carried out for the rest of life.

When a long period of time passes and conservative care doesn’t help, then surgery may be needed. Before surgery is done, the surgeon does a thorough examination. The patient history is taken. This includes things like what’s wrong, how did it happen, what makes it better/worse, what other health problems are present? Symptoms are reported and recorded.

Various tests are conducted to get a complete picture of what’s going on. Where are the areas of weakness and imbalance? Any abnormal patterns muscle activation or movement are identified.

Tests for ligamentous laxity, directional instability, and motion are conducted. The strength and condition of other joints and soft tissues around the shoulder are also tested. Surgery for patients with structural abnormalities of the shoulder will address those imbalances.

There are several different ways to surgically treat multidirectional instability and hyperlaxity. Capsular shift, capsular plication, and thermal capsulorraphy are the techniques used most often. The procedures are usually done arthroscopically at a special shoulder unit by a surgeon who has advanced training in this type of treatment.

The capsular shift procedure is a bit like a tummy tuck. Incisions are made so that the excess tissue can be pulled up and tightened. Different types of incisions and incision patterns can be used depending on where the greatest laxity is located.

With the plication procedure, excess capsular material is pinched and tucked to form pleats. It’s like taking in the waistband on a pair of pants or a skirt that is just too big. The surgeon attaches the pinched pleat to the stiff labrum (fibrous rim around the shoulder joint). This procedure must be done in such a way that the folds of extra tissue don’t get pinched during shoulder motion.

And the last procedure thermal capsulorraphy uses heat to shrink the shoulder capsule. Results from this technique have not been very good, so the method is not recommended much anymore.

The authors conclude that it can be a challenge finding a balance between stability (keeping the shoulder in the socket) and mobility (having the motion needed for everyday activities and sports) for patients with multidirectional shoulder instability from joint hyperlaxity. But there is treatment for those who need it.

When surgery is part of the plan of care, patients who have gotten used to the extra motion must be counseled to prepare for a change in how the arm moves. This is especially true for athletes who have come to depend on that extra motion.

For those individuals who gain attention by showing how they can dislocate their shoulder or by moving in unusual ways, removing that ability may have some psychologic effects. Surgeons treating these patients are advised to carry out honest presurgical counseling about what to expect and how to adjust to the changes.

It’s important to measure before and after results any time treatment is administered for orthopedic injuries. That’s especially true with athletes who are eager to get back into the game. Orthopedic surgeons and physical therapists testing this patient group must make sure they are safe to return-to-sport at a competitive level. Avoiding reinjuries is one reason assessment of motion, strength, and function must be performed.

In this article, the very famous orthopedic surgeon, Frank Jobe, MD and his associates present a new tool for testing function in the arm for overhead throwing athletes. Up until now, surgeons and therapists have relied upon the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. But the DASH isn’t specific to the shoulder or elbow — it looks at the entire arm. So this new tool called the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score (KJOC) might just fill the bill.

They started out getting input from a wide range of sports professionals about what should be on the survey. Sports medicine physicians, orthopedic surgeons, physical therapists, and athletic trainers contributed items for the tool. They put together 13 questions about pain, missed games/practices, flexibility, weakness, stability, change in throwing patterns, and throwing velocity (speed) and power. A few questions also addressed level of competition, history of injury, and effects of arm problems on relationships with others (e.g., coaches, team players, agents, team managers).

They tried to make sure the questions weren’t just directed toward baseball pitchers. Even though that group makes up the majority of overhead throwing athletes who are injured, there are tennis players, volleyball players, swimmers, golfers, and others who could also benefit from this assessment tool.

Once the pilot survey was tested on a small number of athletes, they could tighten up the questions and narrow the survey down to 10-items. The second part of the study involved giving the revised questionnaire to a new batch of 282 healthy overhead throwing athletes at both the college level of competition and professional sports. A second (separate) group of athletes with shoulder injuries were also tested with the Kerlan-Jobe Orthopaedic Clinic (KJOC) questionnaire. These two groups of participants also filled out two other questionnaires. This is done in order to compare the results of the new survey with already established, valid tools.

On the basis of test results, the athletes could be placed into one of three groups called playing categories. The first group was labeled playing without pain. The second group was called playing with pain. And the third group was categorized as not playing due to pain. The KJOC test was used to further compare before and after results for each group.

Analysis of all the data showed that this assessment tool has the potential to help in research being done related to high-level overhead athletes as well as to improve patient care. Whereas the surgeon might say the case has been successful because motion and strength were restored, the patient who can’t return to sports play remains unhappy and feels the treatment was a failure. An outcomes tool like the KJOC measures the patient’s opinion of his or her results (response to treatment) based on function and psychologic health. The beauty of this approach is that it relies on the patient/athlete to be the best judge of his or her outcomes.

The KJOC will be tested further on many more athletes in order to confirm the results reported from this study. Reliability testing on a larger sample size is the next step. Follow-up of all athletes involved in these studies may also provide some additional useful information.

In summary, the new Kerlan-Jobe self-report questionnaire is designed to measure performance outcomes of the upper extremity (entire arm) after injury, treatment, and/or surgery. It has been pilot tested and retested on a larger group of overhead throwing athletes. It is easy to use, valid, efficient, and reliable in its measurements. Improved scores on the test are an indication of improvement in function and can be used with confidence to determine when the athlete is ready to start overhead shoulder motions in competitive sports again.

Ever have a shoulder go out on you? Anyone who has had a shoulder dislocation is understandably concerned that it might happen again. Is there any way to predict who might have a second (recurrent) shoulder dislocation?

That’s what this study is all about. The answer to this question is important because if someone is at increased risk of a recurrent shoulder dislocation, they might want to consider having surgery early on. Surgical repair can stabilize the joint and spare you from waiting to see if the joint will dislocate a second time. On the other hand, if you aren’t at risk for a recurrence, you’ll probably want to avoid unnecessary surgery.

In this study, a group of Israeli surgeons evaluated the benefit of a specific test called the anterior apprehension test. Can it predict the risk of redislocation after the first traumatic shoulder dislocation? As it turns out – no, it wasn’t sensitive enough. But the results may have to do with when the test was administered. Let’s step back and see how they came to that conclusion.

First, what is the anterior apprehension test? This is a clinical test performed after someone has had a traumatic shoulder dislocation to see if the shoulder is unstable. The patient lies on a table face up. The shoulder is placed in a position of 90 degrees of abduction (arm is away from the body). The elbow is bent 90 degrees. The palm of the hand is facing the feet. The examiner holds the elbow with one hand and uses the other hand to rotate the shoulder back (external rotation) while moving the hand toward the patient’s head on the table.

The test is positive if the patient makes a face of pain or apprehension and says it feels as if the shoulder is going to pop out of the socket. The test was done in this study six weeks after the first dislocation after the patient had completed a program of physical therapy to restore normal shoulder motion, strength, and function. If shoulder motion needed for the apprehension test was still limited after six weeks, the patient completed another two to three weeks of therapy before undergoing testing.

There were 52 men who participated in this study. Most were Israeli soldiers or soldiers-in-training. The first dislocation occurred during combat training or while playing soccer or basketball. Everyone was placed in a protective sling for four weeks and then attended physical therapy for two weeks before being tested.

One-fourth of the group had to return to physical therapy because of a lack of adequate shoulder motion to do the apprehension test. Almost half (46.2 per cent) went on to have a second shoulder dislocation on the same side. The second dislocation took place 10 to 17 months later. This time delay did not seem to be linked to whether the soldier had a positive or negative apprehension test.

So, how sensitive is the anterior apprehension test? Sensitivity is the measure of a true positive test. A highly sensitive test means that the test can accurately identify those individuals who are at risk for a second dislocation. In other words, those who test positive are really likely to dislocate the shoulder again. The sensitivity of the anterior apprehension test was only 41.7 per cent. There were many patients (more than one-third of the group) who had a negative test but went on to redislocate anyway. This type of response is referred to as a false negative.

A second important measure is the specificity of a test. Specificity tells us how likely a negative test (not likely to redislocate) is really negative. In this study, the specificity of the anterior apprehension test was 85.7 per cent. That’s pretty good and gives us an idea that if the test is negative, the patient really isn’t likely to dislocate the shoulder again. The chances of a false positive occurring are lower when specificity is high.

With such a low sensitivity rating, this test isn’t really a good way to predict who would benefit from surgery after conservative care (nonoperative treatment) for the first dislocation. It misses too many of the patients who would benefit from surgical repair. It is not a useful diagnostic method for testing shoulder instability after a primary (first) shoulder dislocation.

When it comes to figuring out who should have surgery right away to repair the damage after a first traumatic shoulder dislocation, the anterior apprehension test may not be the best tool to use. Avoiding unnecessary and unsuccessful surgeries is the goal, especially for an active group like military soldiers.

At best, the test results can divide patients into two groups: those who have a higher risk for redislocation after the first dislocation and those who have a lower risk. And based on how the study was conducted, that information is accurate only if the patient has been immobilized for four weeks and received two weeks of standard post-shoulder dislocation therapy.

For military recruits, the test can help guide commanding officers in deciding whether a soldier is ready to return to active duty but it can’t provide an absolute definitive answer as a stand-alone test.

Thinning and tearing of the rotator cuff is a common problem with aging. Efforts to find out how and why this happens have not pinpointed the exact cause or location of these tears.

In this study from Washington University in St. Louis, ultrasonograms are used to take pictures and measure the location, size, and extent of rotator cuff tears in 360 adults from 36 to 90 years old. They established some fairly narrow inclusion/exclusion criteria (who could be included, who could not).

For example, no one was included who had a previous history of trauma, arthritis, or known injury to either shoulder. They could not be taking any medications (narcotics or antiinflammatories) for shoulder pain. And no one was included who had any surgery done on the shoulders in the past.

Those who were included had pain in one shoulder that turned out to be from a rotator cuff tear but were asymptomatic (no symptoms) in the other shoulder. Ultrasound examination was performed on both shoulders. Patients who had a rotator cuff tear on the asymptomatic side were included.

Out of a potential group of 262 patients (524 shoulders), 233 patients (360 shoulders) qualified for this study. Half the group had pain and other symptoms with the tear, the other half were symptom free. The sonograms showed the majority (272 of the 360) shoulders had a full-thickness (all the way through) tear. The rest (88) had a partial-thickness tear.

Three radiologists with more than 10 years of experience examined and analyzed the sonograms. They were measuring three tear variables: tear width, tear length, and distance from the biceps tendon to the tear margin. This information provided detailed data on tear sizes.

Whether the tear was partial- or full-thickness said more about the extent of the tear. And, of course, the exact location of each tear was recorded. The sonogram machines used (three different ones) allowed them to save the pictures taken using the Picture Archiving and Communication System (PACS).

The exact measurements of length, width, and length might not interest you so much. But a quick summary in broader terms might help in understanding what they found. For example, many of the full-thickness tears were fairly small. Most of them were medium-sized with only a few being massive. The width and length of partial-thickness tears tended to be much smaller than the full-thickness tears.

As for the location of the tears, the full-thickness tears were right next to the biceps tendon. Partial-thickness tears were farther away. The relationship between the location of the tear and the biceps tendon is significant (statistically) meaning there is a link here but the meaning of this relationship is not entirely clear just yet.

Most of the tears were within the tendon, not at the point of insertion on the bone. The majority of tears started behind the biceps tendon where the supraspinatus and infraspinatus tendons (the two most commonly torn rotator cuff tendons) meet.

These findings are significant because they weren’t what the researchers were expecting or what is commonly believed about rotator cuff tears. The tears don’t start from the front of the biceps tendon and progress posteriorly (back) but rather the other way around. They questioned whether the tears might have started in several places and met in the middle but there really was no evidence to support this idea.

Knowing that the tears seem to start where the two tendons meet helps explain why some people seem to have an infraspinatus tear but their supraspinatus tendon is the one that looks worn out and vice versa. Why the posterior part of the cuff degenerates is still a mystery. There are some theories to explain it but no known facts.

One of those theories presented in this article is called the rotator crescent concept. The rotator crescent is a crescent-shaped area from the biceps tendon to the bottom border of the infraspinatus tendon. Along the edge of this area is a thick arch-shaped bundle of fibers called the rotator cable.

The cable protects the crescent from stress by its shape and design, which is much like a suspension bridge. With aging, the crescent loses blood supply and starts to thin out. The shoulder mechanics start to rely more and more on the cable. The area that starts to tear is right in the middle of that aging, thinning crescent.

The results of this study will be used to help surgeons understand the pathogenesisof rotator cuff tears (i.e., the how and why of these tears). Knowing where the tears start and how they progress over time is an important place to start. The goal is to direct prevention and treatment, especially guiding surgical strategies.

Any time the rotator cuff is torn and surgery is required to repair or reconstruct the damage, patients are placed in a sling postoperatively to protect the healing tissue. Patients are then given a standard set of shoulder exercises called Codman’s or pendulum exercises to keep the shoulder joint from getting stiff or freezing up.

But there’s a concern that these exercises could put too much tension on the repair and cause a retear. In fact, there’s evidence to show that with large tears (complete rupture), the retear rate is as high as 75 per cent. That’s three out of every four patients! Are these retears in any way linked with doing the prescribed shoulder exercises incorrectly? That’s what this study was meant to help find out.

Thirteen healthy adults (18 and older) without any shoulder problems were the main subjects. Each one was hooked up to wire electrodes placed on the surface of the skin over the muscle being tested. The electrodes can record muscle activity for the muscles of the rotator cuff and transmit this information to a computer for storage and analysis. The participants went through each of the Codman’s exercises — first doing them correctly and then repeating the movement patterns incorrectly.

When performed right, these exercises are done by using the trunk to generate motion of the arm. The patient is standing holding on to a supportive surface with the uninvolved hand while leaning forward and allowing the involved arm to dangle. The trunk and hips are rocked forward and back, side-to-side or in a circular motion. Overflow of motion from the trunk moves the arm forward and back, side-to-side, and in circles clockwise and counterclockwise. The motions can be large or small depending on how much swing the person puts into the hips and trunk.

When done incorrectly, the shoulder generates the motion. This makes the exercises active (using the rotator cuff muscles) instead of passive (protecting the muscles). Test procedures were carried out doing these exercises four different ways: two correctly and two incorrectly. The first set of correct exercises were done using large movements. The second set of correct exercises were done using small movements. Both large and small motions were repeated doing them incorrectly (using the shoulder to move the arm rather than using the trunk to move the shoulder).

The people in the study were also tested doing three other commonly performed daily activities using the arm: typing, brushing teeth, and drinking from a water bottle. These activities were measured as if nothing were wrong with the arm and then repeated with the arm in a sling like the one worn after rotator cuff surgery.

The results showed that muscle activation was observed when the subjects were drinking from a water bottle and while making large movements (correctly or incorrectly). The authors suggest that large movements are either just more difficult to do passively or simply can’t be done passively at all.

Until the results of this study were published, Codman’s exercises were routinely prescribed without knowing if this is really a good idea or not. The goal has always been to keep normal shoulder joint motion without putting any stress on the repair. Now we know that it is possible to do these pendulum exercises in such a way that activates the muscles. The muscle most active was the supraspinatus which is also the rotator cuff muscle that is most often injured.

Although the authors conclude that it might be best to avoid large pendulum exercises in the early days after rotator cuff surgery and to use the uninvolved hand to drink from a bottle, there are some things to note. This study was done on a group of healthy, young individuals. Patients with rotator cuff injuries are often older and obviously the muscle is no longer intact and healthy. Those differences in subject/patient populations could make a significant difference.

Muscle activity was measured using electromyography (EMG). EMG is a measure of muscle activity but not muscle force. The equipment used could tell them that there was muscle activity but not how much or the amount of force. Those details might be important before making any solid recommendations about performance of the exercises and activities measured in this study.

More study is needed to really know for sure the extent to which Codman’s exercises activate the rotator cuff. Repeating the study on a group of rotator cuff patients and comparing the results with normal healthy adults is the next step. The effect of other activities such as pushing a door open, pulling a drawer forward, and picking up a purse or bag after rotator cuff surgery should also be tested.