News Category: Shoulder

Rotator cuff tears come in all sizes from small to large. Sometimes the larger, more severe tears are referred to as massive tears. For some patients, the tears can’t be repaired. But for those who are good candidates for surgery, surgeons have quite a wide range of choices when it comes to surgical approach and technique. In this report, we find out which approach and technique has the best results in terms of retear rates.

The rotator cuff is a group of four muscles and tendons that surround the shoulder joint. Together, these muscles, tendons, and their connective tissue covering keep the shoulder both stable (in the socket) and mobile (moving in all directions). A tear in any one or more of the tendons can cause pain, loss of motion, decreased strength, and reduced function.

Surgery for the shoulder has changed over the years. A wide incision and open surgery has given way now to minimally invasive procedures using arthroscopic techniques. Arthroscopic approaches can be all-arthroscopic or arthroscopic combined with a small incision called mini-open.

Even the type of sutures used has evolved from single-row repairs to double-row stitches. Among suture techniques there’s the transosseous, single-row suture anchor, combined transosseous/suture anchor, double-row suture anchor, and suture bridge to choose from.

Surgeons choose the approach and the repair method based on the type of tear, size of tear, location of tear, and their own experience and expertise with repair techniques. Which method works best?

Well, that question can be measured in several different ways. The surgeon could look at patient symptoms (pain, motion, strength, function) before and after surgery to assess the results. Or, the focus could be on the time between surgery and return to full function (different speeds of recovery). In this systematic review the area of concentration was the retear rate.

Let’s define a few terms here to help you understand what this means. A systematic review is done when researchers look through all the published studies for data on a particular topic. They analyze and summarize all the data collected from the studies selected. Not all studies are included because some may not be high enough quality.

In this case, the topic of interest was retear rates. Retear rates refers to how many patients who have a rotator cuff repair end up tearing the repair requiring yet another surgery. The authors were particularly interested in finding out which repair technique had the lowest retear rate.

Out of 3335 articles published on the rotator cuff 23 were appropriate for this review. Those articles included data on the type of repairs of interest (open, mini-open, or arthroscopic approach; single-row, double-row repair technique). All 23 articles included follow-up MRIs to show the amount of healing over time.

They found that the repair method did affect the structural healing rate. Specifically, the retear rate was lowest when surgeons used the double-row technique. The best results were obtained when the double-row method of repair was used for tears bigger than one centimeter. But the overall data suggests that the double-row repair method should really be used for all rotator cuff tears.

Results were the same regardless of the surgical approach (arthroscopic versus nonarthroscopic). The authors do suggest a few reasons why the double-row technique yields better results when measured by retear rates. The double-row suture improves the biomechanical performance and contact area and pressure. The double-row technique also applies less tension to the healing tissue, which is important during the rehab phase after surgery.

The authors suggest that before surgeons change from one method to another, they should be aware that there is always a learning curve when trying something new or different. Results vary until the surgeon’s technique improves enough to give consistent results from patient to patient. In the case of double-row sutures, the technique requires more extensive releases of the surrounding soft tissue. Getting the right tension on the healing tissue can be a fine art.

According to statistics, the shoulder is the most commonly dislocated joint in the human body, possibly because of the wide range of motion the joint provides, reducing the stability that other joints have. The anterior dislocation is the most common type of dislocation, making up almost 96 percent of shoulder dislocations. This is a dislocation that occurs at the front of the joint, rather than the back.

People who are most likely to experience a dislocated shoulders are young men (aged between 21 and 30 years) and older women (aged between 61 and 80 years). Unfortunately, once a shoulder has been dislocated, it is subject to being dislocated again later on, with less force than the original injury. Some statistics say that the chances of a second dislocation is as high as 94 percent.

Traditionally, first time anterior shoulder dislocations are treated conservatively, without surgery. Surgery is usually reserved for people who have heavy physical activities (for first time injuries) or for repeat dislocations. That being said, there does not seem to be any general agreement as to whether surgery would be beneficial after first time injuries for most people. The authors of this article wanted to determine clinical recommendations regarding how first-time anterior dislocations would be best treated and if there could be an optimal treatment protocol.

Researchers reviewed the medical literature for studies that were randomized controlled trials comparing operative with conservative treatment for primary anterior should dislocation. After excluding studies that were not appropriate, the researchers gathered six articles that described five randomized controlled trials, with one study being reported twice.

Results of the study found that all patients, except one, in two groups in the Kirkley trial were able to return to their pre-injury sports and/or activity levels. In two other studies, the Bottoni study and the Robinson trial saw both operative and conservatively treated patient return in equal numbers. However, one study, done by Wintzell, found that patients who had undergone surgery had only a 73.1 percent average rate of returning to previous levels of activity, while conservatively treated patients had a 65.2 percent rate.

The rates of repeat dislocations, an important aspect of the study, were lower in those who had undergone surgery Two studies found that when the shoulder did redislocate in the operated group, the length of time between treatment and repeat injury was longer than that of the length of time between conservative treatment and re-injury. This finding, however, was not consistent across all studies.

Upon reviewing the results of the published studies, the authors determined that there was not enough information to definitively recommend that surgery should be done on most first-time anterior shoulder dislocations. However, there was enough evidence to support surgery as a first-choice treatment if the patient has a heavily physical occupation or participates in sports activities.

For a variety of reasons, shoulder pain and loss of shoulder function is a problem reported by many patients. Certain age groups, particularly people who are older, have a high number of shoulder problems because of injuries. But, many people with sore or limited use of their shoulders don’t seem to have a predisposing factor that would be the cause. For this reason, the authors of this article suggest that in these cases, “shoulder pain and loss of function are directly proportional to lifestyle choices, including smoking and obesity.” To back up this hypothesis, the authors conducted an on-line survey of 166 people.

Researchers evaluated the respondents by using a shoulder questionnaire that combined three well-known patient-response surveys: the Oxford Shoulder Questionnaire, the Shoulder Rating Questionnaire, and the Subjective Shoulder Rating System. They also asked the respondents how they felt about their range of motion at the shoulder, demographic data, work and sports activities, current medical conditions, and whether they drank alcohol (and how much) or smoked (and how much). The shoulder’s range of motion was determined by showing the respondents 20 photographs of a man moving his arm in various directions. The subjects were to click off the ones that they were able to perform. The study was done online and by volunteers who chose to complete it.

The results of the questionnaire seem to back up the authors’ suggestions regarding lifestyle and shoulder pain and function. From the self-reported shoulder rating system, there was a marked relationship between smoking, high cholesterol, and shoulder problems. The numbers don’t all add up to 166 because of variations in answers. Of the respondents, 37 complained of problems with both shoulders, 37 with just the left, and 63 with just the right. Thirty respondents reported smoking, 19 less than one pack per day and 11 from one to three packs per day. One hundred seven of the respondents did not have an injury that caused their shoulder problem, 56 did report an injury. Of these, 15 had undergone shoulder surgery. Ninety respondents said that they do not drink alcohol, 73 said that they did. Of those who did consume alcohol, 31 drank one or two bottles of beer per week and 26 drank more than two per week. Twenty six of those who drank alcohol drank one or two mixed drinks per week, and 10 drank more than two per week. Twenty six drank one or two glasses of wine per week and 16 drank more than 2 glasses per week.

In evaluating medical issues, the researchers found that 39 respondents reported having high blood pressure, 32 had reported high cholesterol, and 18 reported being obese.

While the numbers of the health and lifestyle issues may not be high, it was the number of injuries and problems that were significant. When evaluating shoulder function according to the Shoulder Objective Rating System, it is done on a scale of one to 100, with the higher the number the better. The respondents who smoked reported a mean of 68.43 (plus or minus 20.68), while the non-smokers rated themselves at 78.70 (plus or minus 17.38). Among those who smoked less than a pack a day, they reported a rating of 73.32 (plus or minus 21.37), but the ones who smoked more than a pack a day weighed in at only 60.00 (plus or minus 17.19).

Taking alcohol into account, people who drank alcohol reported a score of 78.84 (plus or minus) compared with non-drinkers who reported 74.75 (plus or minus). However, the numbers were lower among the people who drank more alcohol. Those who drank two or fewer bottles of beer, mixed drinks, or wine reported a score of 80.80 (plus or minus 13.93), 83.54 (plus or minus 12.64), and 77.27 (plus or minus 16,37), respectively. Those who drank more beer, mixed drinks, or wine scored 75.00 (plus or minus 17.25), 61,70 (plus or minus 22.32), and 68.13 (plus or minus 20.33). In other words, the more alcohol consumed, the lower the score.

Finally, when looking at medical conditions, those with high blood pressure scored only 69.077 (plus or minus 22.509), while those who did not report high blood pressure scored 79.242 (plus or minus 16.266). People with high cholesterol scored 71.063 (plus or minus 22.509) compared with those with normal cholesterol levels who scored 78.214 (plus or minus 17.560). The lowest score was found among people who were obese, at 66.556 (plus or minus 20.004), compared with those within accepted weight guidelines with scores of 78.083 (plus or minus 17.860).

Similar scores were found in the other two types of tests that were completed by the respondents. The authors noted that this study did have drawbacks, including that the respondents were not part of any particular group and were self-chosen, only people who had access to the Internet could participate, and there was no control group with which to compare the results. It was interesting, they wrote, that there was such a significant connection between reported smoking and shoulder function. The link between high cholesterol and shoulder pain is particularly interesting.

The older we get, the more things can go wrong with the body. Rotator cuff tears in the shoulder is one of those problems that seems to go hand-in-hand with the aging process. The rotator cuff is a group of four muscles, tendons, and the connective tissue covering them that surround the shoulder joint. The cuff helps keep the shoulder in the socket as well as moves the shoulder in all directions.

If aging affects the rotator cuff, what’s the effect of older age on recovery after surgery to repair a rotator cuff tear? Is it always true that age is a risk factor for a poor healing and less than optimal outcomes after surgery? Surgeons from the Seoul National University College of Medicine in Korea say, No.

They studied 177 older adults (ages) who had a rotator cuff repair to see how age was related to results. Only adults with full-thickness rotator cuff tears (and no previous or other shoulder injuries or damage) were included. One surgeon performed all of the procedures. Specifics of surgical techniques used are provided in this article.

A great deal of data was collected on each patient because the authors were looking for the relationship between age and outcomes as well as any factors that might be connected with age and outcome. Some of the additional information gathered and analyzed for each patient included sex, activity level, tobacco use, how long the symptoms had been present, range-of-motion for the affected shoulder, arm dominance (right-handed versus left-handed), and type of work (manual labor versus sedentary work).

Imaging such as MRIs and CT scans were used to take a closer look at the rotator cuff. These studies gave the surgeons an idea of how badly damaged the tendons were and how much of the torn area filled in with fatty or scar tissue. The concept of fat filling in where the tendon is damaged is called fatty degeneration. The same images were repeated one year after surgery to show where the rotator cuff had been reattached, an area called the footprint. The integrity of the footprint was evaluated.

Strength was tested using a special machine called a Biodex. Additional tests were done to rate the patients’ pain and function before and after and to measure patient satisfaction after surgery. Any complications such as infection, fracture, damage to the blood vessels or nerves, and shoulder stiffness were recorded for each patient.

There were differences in patient characteristics based on age — for example, the oldest patients were women, nonsmokers, and very low (sedentary) in their activity level. But the overall results didn’t vary among the various age groups. The main difference in results was really linked more to how much the torn tendon had retracted (pulled away from the bone) and the amount of fatty degeneration present between the retracted tendon and bone.

Age was linked with the risk of a retear, though. One-third of the group (all older adults) experienced a retear of the surgically repaired rotator cuff. Turns out age wasn’t as much of a factor in these retears as the type of sutures used (metal or bioabsorbable) and the type of surgical approach (mini-open versus all arthroscopic).

The authors report there are other studies that say, Yes age is a factor, while still others show mixed results. They maintain that the way the factors are analyzed makes a difference. In this study, they used a method of analysis called multivariate regression. Most other studies used univariate regressionanalysis.

The difference in how the data is analyzed makes a difference in whether it looks like age is a direct (independent) factor or not. Univariate analysis shows older age is related to poor results; multivariate not only shows age isn’t an independent factor, it also allows the researchers to find out what factors really are the missing link. In this case, it was tendon retraction and fatty degeneration. That’s a new twist in this argument that will bear further study and discussion.

You wouldn’t know it without being told, but raising the arm overhead requires complex coordinated interactions of the clavicle (collar bone), glenohumeral (shoulder) joint, and scapula. The entire scapulohumeral structure is held together by muscles, tendons, and ligaments. Protective pads called bursa (bursae when referring to more than one) make it possible for smooth, gliding movements of all the parts.

Sometimes people (especially athletes) develop grinding, snapping, crunching, or popping called crepitus that can be felt by the affected person and even heard by others. When crepitus affects the scapula as it moves over the rib cage (thorax), it is referred to as scapulothoracic crepitus or snapping scapula.

That’s the focus of this review article. The authors discuss what happens to normal anatomy to cause this problem, how it differs from another condition called scapulothoracic bursitis, and how to treat both conditions. Fortunately, these problems are fairly uncommon. But when they do occur, the pain and loss of normal movement can result in severe dysfunction of the shoulder and arm. And for anyone involved in overhead throwing sports, the symptoms can be extremely limiting.

What causes scapulothoracic bursitis or crepitus? Normal variations in the shape, size, and position of the scapula can cause muscle and tendon to rub the wrong way. There are those protective pads (bursae) to help ease the tension between muscle and bone or even muscle and muscle. But if there’s a bony bump on the scapula or an extra long end of the bone, the extra wear and tear of muscle/tendon flipping back and forth over the prominence can result in crepitus.

Now, crepitus isn’t always a problem. It turns out that one-third of all adults notice some snapping, grinding, or popping as they move their arm. It never results in painful symptoms or loss of function. What we are talking about here are those people who either suffer some injury to the arm (trauma) or overuse the arm (repetitive irritation of the bursa). Either one can cause inflammation of the bursa (bursitis) and eventually crepitus from scarring and fibrosis.

In a smaller number of people, there are other potential causes of scapulothoracic bursitis and crepitus besides trauma and overuse. For example, bone tumors or bone spurs may result in a reactive bursa. A bursa forms where no bursa normally exists. Muscle tears, muscle atrophy, structural spinal deformities like scoliosis (curvature of the spine), and rib or scapula fractures that don’t heal properly can also create these types of problems.

Whatever the cause, what can be done to fix the problem? Well, first an examination should be done to find out exactly what’s going on. How is the scapula moving over the thorax? Are there obvious alterations in the normal movement patterns and biomechanics? What muscles are too tight, too loose, or weak? Are there any changes in the person’s posture that might be contributing to the problem?

Clinical testing of motion, mobility, and strength along with imaging studies and possibly electrodiagnostic tests help confirm the diagnosis. The examiner, whether an orthopedic surgeon, sports physician, or physical therapist, will also check to see if the symptoms are really coming from the cervical spine (neck).

Once all the information has been collected, a program of nonoperative rehab is the first step. The physical therapist works with the patient to restore normal posture, scapular movement, strength, and endurance. It can take up to six months to create the form and function needed to a return to normal scapulothoracic and scapulohumeral motion. In some cases, the bursa is injected with a steroid to reduce swelling and irritation from the inflammatory process.

When conservative (nonoperative) care doesn’t solve the problem, then the surgeon gives some thought to operating. The inflamed bursae may be removed or alternately, a portion of the scapula may be cut out. Either one of these procedures takes pressure off the soft tissues that are getting pinched or rubbed against.

Some of these surgeries can be done arthroscopically, while others require open incision. The exact surgical method and technique to use for a snapping scapula that doesn’t respond to conservative care isn’t known. In fact, there’s a lot of debate over this issue.

Studies that have been done so far show equally good results no matter what surgical approach is taken. Success is defined by a pain free return to preinjury activity levels at work and in sports or recreational activities. Patients who choose surgery should be warned that there are a few potential complications such as recurrence of the same pesky bursitis and/or damage to the dorsal scapular nerve.

If you’ve had a rotator cuff tear repaired but it didn’t heal and/or it tore again, should you go for a second (revision) surgery to repair the recurrent tear? This is one of the few reports on the results of those patients who do go ahead and have the second procedure. Does the tendon heal after the second operation? What are the results in terms of pain, shoulder function, and motion? Let’s find out.

In this study 21 patients with failed rotator cuff surgery (either because of failure of tendon healing or due to a retear of the previously repaired tendon) had a second operation to try and correct the problem. No one rushed into the second surgery. They all tried at least six-months of rehab after the first repair. But persistent pain and loss of motion and function sent them back to the surgeon for help.

But what’s best? Learn to live with the limitations? Keep trying rehab? Or have another operation that may or may not work? Having some idea of how others have fared after a second surgical attempt might help surgeons know how to advise their patients in this type of situation.

There was nothing special or unusual about the patients who had the revision surgery. They included men and women ranging from 47 to 73 years old. Slightly more than half had the injury on their dominant side. Most were treated the first time somewhere else and were now being sent to the Shoulder and Elbow Department of Orthopaedic Surgery at Washington University in St. Louis.

Because this is a teaching hospital involved in research, patients were assessed, tested, and questioned thoroughly to gather baseline information before treatment. They were retested after surgery to evaluate before and after results. Ultrasound imaging was done a year after the revision surgery to take a look at the healing tendon.

The exact revision surgery varied from patient-to-patient depending on what the surgeon found when looking inside the shoulder. And there was a wide range of problems present: biceps tendons torn fully and retracted too far to repair, cartilage holes and tears, complete tears of one or more tendons, degenerative changes in other tendons, irregular bone edges. Everything was carefully repaired or reconstructed and the patients all went back to rehab once again.

Rehab was a slow, but steady process supervised by a physical therapist in consultation with the surgeon. After six weeks in a sling and pillow to hold the arm in slight abduction (away from the side), the therapist moved the shoulder joint through its motions passively (without the patient’s assistance). Patients weren’t allowed to help move the arm for a full 12 weeks after surgery. By the end of four months, they could start a strengthening program. The therapist helped each patient prepare to return to work and created a rehab program that would enable them to meet individual work demands.

And the results? Well, almost everyone did get pain relief and improved motion and function. Most of the patients improved enough to be able to return to work, play a sport if so desired, and resume daily activities. But less than half (48 per cent) had an intact repair as seen on ultrasound. Five of the 21 patients (about 25 per cent of the group) considered themselves disabled. With ongoing pain, they just weren’t able to even do their daily activities.

The surgeons found that single-tendon repairs were more likely to be successful than multiple-tendon repairs. In fact, statistical analysis showed that 70 per cent of the single-tendon repairs were in good shape. Only 27 per cent of the multiple tendon repairs made it. Intact tendons did improve shoulder strength. The older the patient, the greater the chance of a poor outcome.

And in the end, even for those whose revision surgery wasn’t completely successful, the patients were better off than before surgery with less pain and more function. Would the surgeons recommend revision surgery in all cases? Maybe not — patients with multiple tears should be advised that surgery might improve their pain more than their function.

Older adults with multiple tears may not have the full result desired. With massive tears of more than one tendon, surgeons may advise this group that the damage cannot be repaired. For those who do have a revision operation, a slow but steady progression in rehab may be best. Giving the repaired tendon(s) time to heal before stressing them may yield better results than a more aggressive program.

Try this: reach your right hand behind your back and touch your fingers to your spine (go as high up as you can reach easily and comfortably). Now do the same thing with the left hand. Can you do it? Can you reach equally on both sides? You have just tested for tightness of the posterior capsule of the shoulder by internally rotating the arm.

The posterior capsule is a band of fibrous tissue that interconnects with tendons of the rotator cuff of the shoulder. The rotator cuff is made up of four muscles and their tendons. They cover the outside of the shoulder and form part of the posterior capsule to hold, protect, and move the joint.

If the posterior capsule is too tight, internal rotation motion of the shoulder can be limited. That type of shoulder tightness can lead to shoulder problems such as impingement, rotator cuff tears, and damage to the labrum. The labrum is an extra rim of fibrous cartilage around the otherwise shallow shoulder socket. It helps keep the shoulder in the joint and prevent dislocations.

What’s the best way to stretch the posterior capsule? That’s something physical therapists are studying. Patients with posterior shoulder tightness show up most often in a sports clinic. Athletes who can’t fully rotate the shoulder inwardly can be at a disadvantage in their sports performance. This is especially true for athletes involved in sports that require overhead throwing.

There have been some studies that support a stretching exercise for this problem. Others suggest performing a joint mobilization technique. Joint mobilization involves gliding and sliding the head of the humerus in the socket as far as it will go and gently rocking or oscillating it to gain mobility. Someone else (like a physical therapist) has to do this to you — it’s difficult to do it to yourself.

In this study, a group of therapists compare which works better: just the stretching technique or stretching combined with joint mobilization. They didn’t include a control group (people with this problem who don’t receive any treatment) or a group who just got mobilization. All the subjects were healthy college-aged adults. They each had at least a 10-degree difference in shoulder internal rotation from one side to the other. That’s why they were chosen for the study. None of the participants had any actual pain or other symptoms.

The programs were carried out over a period of four weeks. Everyone in both groups did the posterior capsule stretch. This was done by reaching the affected arm across the chest and using the hand on the uninvolved side to pull slightly and hold for 30 seconds. The stretch was repeated five times at least three to four days each week for the four weeks. Everyone filled out a log to post what days they did the exercises and how many they did.

For the people in the joint mobilization group, besides doing their stretches, a physical therapist also mobilized their involved shoulder for 10 minutes at least twice a week for four weeks. Results were measured and compared between the two groups using range-of-motion measurements for shoulder rotations (internal and external rotation were both measured). Measurements were taken at the end of the four-week treatment period and again four more weeks later (eight weeks after the start of the program).

No differences were noted in external rotation but internal rotation increased in both groups. This increase was observed right at the end of the four-week treatment period. Four weeks later, there was a loss of the internal rotation originally gained. The stretching plus mobilization group had the best results. At the end of the eight weeks, they had maintained more of the motion gained from treatment compared with the stretching only group.

What does this tell the therapists? For athletes (and other patients) with a tight posterior shoulder capsule, a stretching program may not be enough. They may have to add joint mobilization while continuing to have the patients stretch at home on their own.

The subjects in this study weren’t athletes, didn’t have any sports involvement, and had no known shoulder problems. So before jumping in and applying this new information, additional studies are going to have to be done. The procedures will have to be used on patients with diagnosed posterior shoulder capsule tightness associated with impingement or rotator cuff or labral lesions. This study was not able to compare the effects of the treatment on normal versus damaged tissue — that could make a difference in how effective stretching or stretching and joint mobilization might be.

On the prevention side of things, we know that athletes with limited internal shoulder range-of-motion are at risk for future shoulder injuries. Identifying those individuals with tight posterior shoulder capsules and putting them on a stretching program might help reduce injuries. Again, this is something that needs to be studied and confirmed (or disproven).

Shoulder dislocations: how often do they occur and who is affected most often? Those are the two pieces of information sought in this study. And to find out just who is experiencing shoulder dislocations in the United States, a special collection of data from 100 hospital-based emergency departments was analyzed.

Almost 9,000 patient cases were recorded over a four-year period. The majority of these shoulder dislocations occurred as a result of a sudden fall. Two age groups were represented: between 20 and 29 and between 80 and 89. The younger group were more likely to fall during a sports or recreational activity. They were either athletes or military personnel (and sometimes military participating in sports). Football and basketball accounted for the majority of dislocations. Falls at home were more likely to be reported by the older adults.

In the younger group, men were represented two and a half times more often than women. The type of fracture and whether it was the first dislocation or a recurrence (second) dislocation were not recorded at most hospitals. Anyone with additional shoulder injuries sustained at the time of the shoulder dislocation (e.g., fractures, sprains, tears, contusions) was not included in this study.

The authors also took a look at whether or not shoulder dislocations occurred more or less often by race. Though more whites had a reported dislocation, analyzing the data and carrying out statistical calculations showed that no individual race (white, black, Hispanic, Native American, Asian) had more cases of shoulder dislocation than the others.

By now you may be wondering what difference does it make how old people are when they dislocate their shoulder? How can knowing what they were doing when they fell, or whether they are black, white, male, female, or other make a difference?

The intended goal of collecting this information is to try and prevent these injuries from happening. There has been a significant increase in the number of shoulder dislocations in this country over the past 20 years. And it is believed that the data collected doesn’t tell the whole story. Many people manage to put the shoulder joint back in place and don’t report it at all. Others see their primary care physician or go to an orthopedic surgeon (perhaps someone who has treated them in the past for other things or even for a previous shoulder dislocation). Cases like that don’t get reported through the hospital emergency department data base.

There must be a reason for the rise in shoulder dislocations. Studies like this might be able to pinpoint what some of those risk factors may be. If possible, once those risk factors are identified, a prevention program might help. Decreasing the incidence of shoulder dislocations would reduce pain, suffering, cost, loss of income and productivity, as well as keep our athletes on the field and our soldiers on duty.

Taking a sample of shoulder dislocations from across the country doesn’t include everyone but it does give us a peek inside the window. This kind of data can help identify trends of risk and maybe help us develop future prevention strategies. For now it looks like the group to start with are active young men and older adults. Strategies that work best to prevent shoulder dislocations may be the next step in this discovery process.

In this 15-page review of overhead throwing sports, physical therapists provide insight and depth into the prevention and treatment of shoulder injuries. These athletes move the throwing arm through a wide range of motion over and over and over everyday whether in practice or in competition and sometimes both on the same day.

Despite being in top shape, there is a risk of microtrauma for these athletes from repetitive throwing. The soft tissues of the shoulder aren’t invincible — they do have their limit. When the athlete’s physical actions exceed the physiologic or tensile strength of the joint, injuries can occur.

The sports physical therapist’s job is to help athletes prevent injuries. Once an injury has occurred, then the therapist guides the athlete through a rehab program to recovery and return-to-sport. The principles of injury prevention and treatment programs along with rehabilitation progression are the two main topics of this review.

The first order of business on the prevention side is to make sure the athlete has the right kind of shoulder and arm motion needed for throwing. Most of these athletes have more motion than you or I. They have to be able to cock the hand way back behind the head in order to get enough speed to shoot the ball forward fast. Any loss of shoulder motion increases the risk of injury. Gentle stretching exercises are used to keep the arm limber throughout the season.

You won’t be surprised to know that strengthening the muscles of the entire upper extremity (arm) including muscles surrounding the scapula, shoulder joint, upper arm, elbow, forearm, wrist, and hand is the second order of the day. What you probably don’t realize is how complex the muscle activity is when throwing a ball. Besides contracting and releasing, these muscles must also help the arm decelerate (slow down) at just the right moment. Each muscle has its own unique jobs that require different types of exercises to strengthen and train them.

Together, the muscles, tendons, and ligaments of the shoulder complex do two things: stabilize (hold the joint firmly in the socket) and mobilize (allow movement). These two functions require fine-tuning called motor control or neuromuscular control.

Improving motor control actually requires a whole different set of activities and exercises. The therapist uses terms like rhythmic stabilization, closed kinetic chain exercises, and plyometrics to describe this portion of the prevention and rehabilitation program. You might have heard about plyometrics if you listen to any of the sports radio shows or watch sports TV. This is a fairly new concept designed to help increase the speed and power of muscle contraction and movement.

On the prevention side of the equation, core training and lower body strengthening are keys to off-season training and in-season maintenance. Anything that happens in the lower body is going to affect the upper body and especially that important throwing arm. The entire body must be tuned, strong, flexible, stable, and hold up under strenuous conditions (a sign of endurance). There isn’t one exercise that addresses all of these functions. That’s why the sports therapist’s job is both so challenging and rewarding.

But that’s not the end — there’s the other side of the prevention-rehab equation: injuries requiring attention both during the acute (recent) and chronic (long-term) phases. The goals of treatment and methods used will vary depending on the degree of injury, whether or not the athlete has had surgery, and whether the athlete is dealing with an acute or chronic situation.

The authors provide many color photos of the prescribed exercises along with helpful tables to guide treatment from the acute phase through the intermediate phase to the advanced strengthening phase and return-to-sport completion of the program. Goals are outlined for each phase along with specific exercises and activities for each one. Sports specific exercises become the focus of the final phase as the athlete returns to the field, first in practice sessions and then in competition.

Sports physical therapists are instructed to see the athlete as a whole person, not just an overhead throwing machine. There are many fine details to pay attention to such as posture, position of the scapula (shoulder blade), areas of muscular tightness or imbalance anywhere in the body, areas of incoordination, loss of proprioception (joint sense of position), and kinesthesia (body awareness) to name a few. Specific exercises and drills to restore these features and functions are discussed in detail.

And finally, the most common shoulder injuries in overhead throwing athletes are reviewed. These include shoulder instability, tears of the labrum (rim of fibrous cartilage around the shoulder socket), impingement (pinching of soft tissues inside the joint), and tendinitis.

Most of these injuries require a special look at throwing mechanics to identify the cause(s) and risk factors. Treating the injury may not be enough — the therapist has to figure out what the athlete is doing (or not doing) in order to keep that same injury from occurring again. And often there isn’t just one problem area. Any change or imbalance in joint motion, flexibility, strength, posture, and stabilization can be a contributing factor.

The authors do a very good job showing how challenging it can be to work with overhead throwing athletes. Every aspect of their sport activity, physical condition, and individual differences must be considered when trying to avoid injuries or treat them after the fact. The description of the proper treatment program and reminder to progress slowly but surely through each phase is a valuable tool for any sports therapist.

Large tears of the shoulder rotator cuff are determined by size (more than an inch wide) or by how many tendons are affected (two or more of the four tendons that make up the rotator cuff). Treatment isn’t just a simple surgery to patch everything together. Large or massive tears (as the surgeons call them) often don’t heal well. Poor tendon healing, repeated tears, and tears that simply get bigger over time can be obstacles surgeons (and patients) face.

Some tears can’t be repaired. Others require extensive surgery to debride (clean up) any frayed edges and remove tissue damaged beyond repair. A tendon transfer may be needed. No matter what decision is made, there are various techniques to choose from when performing the procedure. The bottom line is to restore the shoulder to as near normal as possible and have the repair hold up over time.

To help surgeons reach this goal, the authors of this update review ways to do rotator cuff repairs, what to expect in terms of results with each type of repair, and ways to assist tendon healing. First of all they point out that when rotator cuff tears occur without trauma, there are usually degenerative changes already present. That means healing is going to be affected. The tissue is stiffer with scarring (fibrosis) and loss of good blood supply at the cellular level. The tissue is of such poor quality that surgical repair may be impossible.

For patients who are medically unable to have surgery and for those who don’t want surgery, physical therapy has been shown effective as a nonoperative approach to treatment. The therapist shows the patient ways to move that will reduce the stress and pressure on shoulder structures. At the same time, an exercise program is used to strengthen the muscles that still work normally in order to restore as much normal shoulder function as possible. Steroid injections may be used to help with pain control and improve motion during therapy.

For patients whose rotator cuff can be repaired, the surgeon must consider how the rest of the shoulder joint and soft tissues compensate for the loss of tendon integrity. Shifts occur in the shoulder structures that can affect shoulder stability and strength. Other factors such as age, tear size, smoking, diabetes, and the use of antiinflammatories must be considered because any of these can affect the final results or outcomes of surgery.

Much has been written about how shoulder surgeries should be performed. Is the minimally invasive arthroscopic technique better than the open incision approach? There are pros and cons to both but it’s starting to look like arthroscopic technique has improved enough that the results are neck and neck between the two operative methods. The final proof of which one is better may come when long-term results (10 to 20 years later) can be reported. Until then, surgeons continue to look for ways to improve repairs with different suture techniques, suture materials, and combinations of these techniques. The authors provide descriptions and drawings of different stitches that can be used including a tensionless technique called interval slides.

A new area of focus in tendon healing is called biologic augmentation. Instead of using tendon transfers, various agents (biologics) are being tried to help bridge the gap between the torn and retracted tendon and bone where the tendon should be attached. Collagen (building material for soft tissues) from animals such as pigs and a portion of the small intestine are two experimental implants being investigated. Growth factors have been tried but without much success. They do stimulate tissue to develop but it’s often just poor-quality scar tissue and not real (strong) tendon tissue.

Maybe one of the most useful aspects of this article is the treatment algorithm (decision pathway) provided by the surgeons who wrote the article. When the surgeon is working with a patient who has a massive rotator cuff tear, the algorithm starts with conservative (nonoperative) care and then branches according to whether the patient has a rotator cuff tear that can be repaired or one that is irreparable. On the repair side, the next step is to decide whether the procedure should be done arthroscopically or with an open incision. Of course, then the next step is to determine what surgical technique is best for that patient.

For massive rotator cuff tears that can’t be repaired, surgery may still be an option. Instead of trying to repair and reattach the tendon, the area may be cleaned up as best as possible with a partial repair. Or a tendon transfer may be able to salvage the situation. Experimental techniques described may someday become a mainstream part of repair and/or salvage of massive cuff tears so they are listed off to the side at the bottom of the chart.

When it’s all said and done, the surgeon must still evaluate each patient on and individual basis. The location, size, and condition of the tear guide treatment. The surgeon may not have all the information needed about these factors until during the operation when they can take a look and see what’s really going on. Then all other variables come into play such as patient goals, age, health, and condition of other shoulder structures.

There isn’t much a surgeon can do right now about tired, worn out tendons that rupture. Until science delivers safe, effective, and reliable biologic augmentation, surgeons do the best they can with what they have to work with. And as it turns out, that is often enough to give patients a stable, workable shoulder with reduced pain and improved function.

Ever since arthroscopic surgery became a possibility for shoulder surgery, surgeons have been debating and comparing the open incision technique against arthroscopy. Which one is better? Does it even matter in the end? The results of this meta-analysis may be able to answer the question once and for all for at least one procedure: acromioplasty.

Acromioplasty is the removal of the end of the acromion, the round end of a curved piece of bone that comes from the back of the scapula (shoulder blade) over the top of the shoulder. Some of the shoulder muscles of the rotator cuff pass under the acromion as they travel from the scapula to the humerus (upper arm bone). And for various reasons, the rotator cuff can get pinched there causing a painful problem called subacromial impingement syndrome. Subacromial just means under the acromion.

So you can see how removing the end of the acromion can take care of the problem. That brings us back to the original question: what’s the best way to surgically remove the end of the acromion so it can no longer pinch the rotator cuff as it passes under the bone?

A meta-analysis has the power to end debates because it provides enough subjects to reach some final conclusions. After searching all the medical literature published from 2000 to 2007 plus all the presentations made on the topic at four major orthopedic meetings held during that time, the authors were able to come to shed some light by comparing results between the two procedures. They found nine studies that directly compared arthroscopic versus open acromioplasty surgeries.

It turns out that by the end of 12 months (one full year), patients had equal results in terms of complications after surgery and final outcomes such as range-of-motion, pain, and function. And patients reported equal levels of satisfaction with either procedure. It’s what happens during those 12 months that’s of significance. For example, patients undergoing the arthroscopic procedure were able to leave the hospital faster and go back to work sooner. On average, patients having the arthroscopic procedure were back at work two weeks before patients in the open acromioplasty group. And the open acromioplasty took longer, so combined with lost wages from a delay in return-to-work, there was more expense for operative time with the open technique.

Some surgeons think arthroscopic acromioplasty is a better way to go for several reasons. First, they are able to avoid cutting through the deltoid muscle. Deltoid sparing techniques make it possible for the patient to start moving the arm right away after surgery. They can get into rehab without delay — and for competitive athletes, that is a very important feature. For those who care, the incisions for arthroscopic surgery are much smaller and far less noticeable than the scar that results from the open incision.

In summary, small studies comparing arthroscopic to open incision acromioplasty have not been able to consistently show how these two techniques compare. Results have been contradictory from one study to the next. That’s why pooling the data from high quality studies in a meta-analysis is so helpful. With enough patients undergoing the same two procedures, analyses can be conducted that reach statistical significance. The authors conclude that although arthroscopic acromioplasty isn’t superior to open incision surgery in every way, it does have some important socioeconomic advantages to consider.

Rotator cuff disease is really a condition where one of the four tendons that stabilize the shoulder joint is damaged or injured. It’s one of the most common causes of shoulder pain. Sometimes rotator cuff injuries are treated with surgery, but others don’t require surgery and can be treated by , nonoperative, no surgery, treatments.

Determining how effective shoulder treatment is often depends on the system used to measure the success and how the scores are obtained. There are many methods available aside from the two in this study, such as the Constant score, UCLS score, Western Ontario Rotator Cuff Index, Penn Shoulder Score, and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

The authors of this study wanted to determine the smallest difference it takes for a patient to feel that the treatment has helped his or her shoulder. To do this, researchers recruited 81 patients, average age 51 years) who had been diagnosed with either tendinitis (inflammation and irritation of the tendon) of the shoulder (14 patients total) or a tear in the rotator cuff (67 patients total). The researchers gathered data on the patients’ history, a physical examination and x-rays of the affected shoulders. If patients had undergone magnetic resonance imaging (MRI), this information was also included. Some patients who were diagnosed with tendinitis but who did not have an MRI may actually have had a torn tendon, but this was not recorded.

To get the patients’ point of view regarding their shoulder problems, they filled out baseline questionnaire forms, including the American Shoulder and Elbow Surgeons score (ASES) and the Simple Shoulder Test (SST). The ASES gave scores according to the pain and function of the shoulder, using three sets of scores: the 15-item function, 15-item pain, and four-item assessments. The SST asks patients about how they are or aren’t able to function with their shoulder the way it is at the time the test is taken.

The types of non-surgical treatments the patients received varied according to their own needs. They included:
– rest
– application of ice
– restricting or modifying activity
– physical therapy
– anti-inflammatory pain medications
– cortisone injections into the shoulder

After at least six weeks, the patients were reevaluated with the questionnaire, the test, and three extra questions:

1- Since your last clinic visit, has there been any change in the function of your treated shoulder?
2- Since your last clinic visit, has there been any change in the pain in your treated shoulder?
3- Since your last clinic visit, please rate your response to treatment.

The results showed that there was a difference in scores in the SST of at least 2.33, in patients who had improvements in their shoulder, although many patients had more significant changes. Patients who had no positive progress had from a negative 0.33 point change up to only 1.72 points change. When looking at the ASES scores, the researchers found that the minimum number that showed changes were between 12 and 17: 12.01 for the 15-item function, 16.92 for the 15-item pain, and 16.72 in the four-item assessments.

Taking these numbers, the researchers were able to determine the lowest scores that would show that there was improvement in the affected shoulders. The authors did point out that the study had some limitations, not the least of which was that they may not have had accurate diagnosis for all the patients. As mentioned above, some patients were diagnosed with tendinitis, but they could have had a tear that was not known about.

Question: If you have a torn rotator cuff (the tendons and muscles surrounding the shoulder), can you get better without surgery?

Question: If you have surgery to repair a damaged rotator cuff and you end up retearing the same area — was it worth it to have the surgery in the first place?

Question: If you rerupture the repaired rotator cuff, what happens? Does your pain increase? Do you lose shoulder motion, strength, and/or function?

The authors of this article have been studying rotator cuff defects, their clinical effects on patients, and results of treatment for many years. Now, they turn their attention to what happens when one of these repairs retears.

This is a follow-up study of a group of 15 patients who were previously assessed three years after their first surgery for a torn rotator cuff. They were all known to have developed a retear of the repaired tendon. The researchers continued to follow them for another four years and now report on measures of pain, shoulder motion, strength, and function.

Besides using some standard tests to measure these variables, they also took ultrasound pictures of the tear to show what was going on inside the rotator cuff during those follow-up years. Ultrasound is a quick and inexpensive way to see if the tear is changing, either healing itself or getting larger (and by how much). None of the patients had a revision (second) surgery to repair the retear after the first operation to repair the initial injury.

There aren’t very many studies on the subject of what happens to patients who experience a second tear of a rotator cuff. And part of the reason for that (as these surgeons have found out from their own studies) is that a lot of patients don’t even know they have retorn the repair. They don’t have any pain. And any change in motion, strength, or function doesn’t bother them enough to have it checked out.

In the process of following their own patients, the authors discovered that more than one-quarter of the patients treated in their special sports medicine shoulder practice ended up with retears. The patients still had better strength and function with less pain than before their first surgery, so they were happy despite the retear.

At first glance, all may seem hunky dory. Patients weren’t distressed, so why do another surgery to repair the second tear? Well, that’s the rub. How do we know that leaving these retears alone isn’t doing a disservice to the patient? What if years down the road, the structure deteriorates beyond repair? It may be that early revision surgery is a better idea than previously thought.

That’s where this study comes in. By following patients with a surgically repaired but now retorn rotator cuff over time, it was possible to see what happens. That’s referred to as the natural course or natural history of a condition. Here’s what they found.

You’ve probably seen the speed of some animals on TV shows. The smooth, sleek cheetah has been clocked at 60 to 70 miles per hour. The large, sturdy bison can run 40 miles per hour — and get up to that speed in a matter of minutes. But do you know what’s the fastest recorded human movement? The throwing arm of athletes like quarterbacks, softball players, and tennis players. It’s true!

And guess what comes with throwing a ball forward 70 to 90 miles per hour over and over and over? Stress on the shoulder, microtrauma of the soft tissues, and changes in alignment and position of the entire shoulder complex. Specialists in the world of sports medicine must be on their toes to recognize problems early and intervene to prevent injuries.

In this article, the clinical examination for the overhead throwing athlete is reviewed. Details of the athlete’s history, shoulder and arm range of motion, and condition of the joint movement are presented. Changes in the position of the scapula (shoulder blade) that come about after 100s and even 1000s of throws are discussed. These are normal adaptive changes, not necessarily pathologic changes but they do affect how the shoulder moves and functions.

The authors provide tests to assess joint laxity (looseness), scapular position, muscle strength, and proprioception (joint sense of position). Photos showing the examiner performing each test are provided. A special section on testing for rotator cuff injuries and labral tears is also offered.

This review is designed to help sports specialists working with overhead throwing athletes recognize variations from normal movement and function that naturally occur after months of training and competition. Recognizing acute (short-term) and chronic (long-term) changes and adaptations that occur help the examiner narrow down what puts the athlete at risk for injury and what’s protective. We’ll talk more about this in a little bit.

Pain while throwing is the most common physical complaint reported by athletes when something is wrong. The pain may have started with a specific throw but it’s most likely the result of a problem that has progressed and gotten worse over time. Often the athlete isn’t even fully aware that something is happening until a major problem develops.

The careful examiner takes into consideration everything the athlete says about how he or she thinks the injury occurred. But asking questions like, What phase of the throw brings on the most symptoms? can help isolate the soft tissue structures involved. For sports medicine specialists, seeing an athlete lose speed of pitch, serve, or throw is a yellow (caution) flag. Hearing athletes say they can’t get loosened up or it takes much longer to warm up are additional red (warning) flags.

At that point, it’s time to take a look at the athlete’s range-of-motion and throwing pattern. The clinician will look for strength imbalances, loss of soft tissue flexibility and/or loss of motion, muscle weakness, and changes in joint stability. Assessment of movement may reveal alterations in throwing mechanics that could translate into injury.

Most overhead throwing athletes end up with too much shoulder motion in external (outward) shoulder rotation and a loss of flexibility in internal (inward) rotation. Joint laxity (excess motion) can be a big problem, especially for the athlete who started out with pretty loose joints to begin with. But joint laxity is one problem that may be prevented with the proper stretching and strengthening program.

More recently, attention has been brought to the importance of scapular position and movement. Even a small amount of abnormal tilt of the shoulder blade can affect how the shoulder muscles contract to move the arm. Studies have documented a loss in shoulder muscle strength linked with a scapula that is forward-tilted and protracted (slid forward over the trunk). A special tool called an inclinometer can be used to test the position of the scapula and measure its rotation.

Once an injury has occurred, the sports specialist conducts special tests to find out what’s going on. Is it a bursitis? Rotator cuff tear? Impingement (pinching) of a tendon? Certain positions of the shoulder/arm relax some soft tissues while tightening others. Finding positions of comfort and discomfort help identify what might be affected.

Tests to detect a rotator cuff tear include the relocation test and internal impingement tests such as the Neer test or the Hawkins impingement test. Superior labral injuries are more difficult to diagnose because the athlete often has a rotator cuff tear (partial or full) along with a superior labral tear from anterior to posterior (SLAP). A SLAP injury is a front to back tear of the labrum, a rim of cartilage around the shoulder joint.

There are many tests used to identify a SLAP lesion. Most are familiar to sports medicine experts but two new tests including the pronated load test and the resisted supination external rotation test may be less familiar. These two tests use positioning of the shoulder and forearm along with muscle contraction to place tension on the labrum and reproduce the patient’s symptoms. The tests are described with photos of an examiner performing the tests on an athlete.

Orthopedic surgeons, physical therapists, athletic trainers, and other sports medicine specialists will find this article informative and helpful when examining and training overhead throwing athletes. There’s plenty of good information to help these specialists evaluate athletes in an effort to prevent injuries and then recognize and treat them when they do occur. These athletes can present a very complex challenge to the best of sports medicine’s experts!

With the development of arthroscopic surgery, surgeons have been able to repair rotator cuff tears (RCTs) in the shoulder with minimal trauma to the rest of the shoulder. But sometimes the repair doesn’t hold and the patient retears the tissues. When that happens, is it okay to do the revision (second) surgery arthroscopically? Or should the surgeon perform an open incision for that second surgery?

That’s what this group of surgeons set out to investigate with 54 of their own patients. The patients ranged in ages from 22 to 82. The surgeons saw them over a period of two years for arthroscopic revision repair of the rotator cuff. Everyone was followed for at least one full year. Some patients came back for additional testing for almost three years.

The patients were tested before and after the second surgery comparing strength, range-of-motion, function, and pain levels. All kinds of data was collected about each patient. The authors were hoping to find some way to predict who might have a positive result and who was at risk for a failed second surgery. For example, age, gender, hand dominance, past medical and surgical histories, occupation and work levels (light, medium, heavy), use of tobacco and/or alcohol, and number of previous shoulder surgeries were all recorded and analyzed with the results.

Besides looking at the social and medical histories, the surgeons also made note of the number and type of fixation (anchors and sutures) used during the revision procedure. Sometimes only a single-row of fixation was needed. Tissue quality and tension placed on the repair determines whether a single versus double-row of sutures/anchors is needed.

Any repairs made to other damage in the shoulder were also taken into consideration. Before and after imaging studies were done using X-rays and MRIs. The presence of bone spurs and other signs of osteoarthritis were revealed by these additional imaging studies.

After surgery, every patient participated in a six-month long rehab program. The program was directed and supervised by physical therapists. There were three phases: passive motion while the shoulder was immobilized in a sling, active motion after the sling was discontinued, and strengthening and conditioning.

Every detail of time in rehab, cooperation and compliance, and final functional capacity was observed and reported. The researchers left no stone unturned when it comes to looking for any factor that might possibly tip the surgeon off as to the final result (success versus failure). They even had outside experts evaluate and test the patients to avoid any potential bias.

Patients were carefully selected for this study. Focusing on a subgroup of similar patients makes it possible to reduce the effects of too many variables (factors) thrown in together. In this study, they excluded anyone who had a partial-thickness tear or tears that couldn’t be repaired. Only patients with full-thickness tears (ruptures) that could be operated on were included. Patients were taken out of the study any time the surgeon started with an arthroscopic procedure but had to switch over to an open repair.

Most of the studies already published about revision surgery for rotator cuff repairs focus on the results of open surgery. An open incision gives the surgeon easier access to the area but it is more invasive than arthroscopic surgery. Arthroscopy makes it possible to see inside the joint and clearly identify the type of tear and extent of damage. With a tiny TV camera on the end of the scope, the surgeon can probe the area and look for any other soft tissue disruptions or joint lesions that can’t be seen otherwise.

When it was all said and done and the patients had been analyzed in many different ways, they found that the results weren’t optimal using arthroscopy to do the revision. There was some pain relief and improved shoulder function but 10 per cent had a failed response. These patients faced yet another operation, including shoulder replacement.

Patients most likely to have a failed revision surgery were those who had already had more than one previous surgery on the same shoulder. Anyone who couldn’t lift the arm overhead seemed to have the worst outcomes.

And it turned out that gender was also an important factor. Women were more likely to have a poor result compared with men. Patients most likely to get back to work were those with the smallest tears who didn’t smoke and whose job did not require heavy lifting or manual labor.

The authors concluded that revision of rotator cuff repairs that retear can be done arthroscopically. If the surgeon suspects there’s a complex tear pattern and/or other damage present, then arthroscopy over open incision is still the better choice. The open incision technique might be better for patients with negative predictive risk factors (e.g., women, smokers, those who have had previous shoulder surgeries).

Either way, patients should be warned that the results usually aren’t as good as if the shoulder were being repaired for the first time. The goal of revision surgery is to improve patient comfort and function with the least amount of scarring and complications. If there is some way to reduce the risk of failure, surgeons want to know that. The results of this study may help surgeons when evaluating which surgical approach to take when repairing a torn rotator cuff for the second time.

Orthopedic surgeons are likely to suggest patients delay total shoulder replacement (TSR) based on age. Studies show that patients who are 50 and younger just don’t have as good of results as patients over 50 with this procedure. But this study brings new data that suggests maybe we are barking up the wrong tree. It’s not age that’s the determining factor but rather, the cause of the problem!

It turns out that younger patients with shoulder pain and loss of function severe enough to warrant replacing the joint is more often due to capsulorrhaphy arthropathy than degenerative joint disease. Capsulorraphy arthropathy refers to arthritis that occurs after a previous surgery on the shoulder. That surgery might have been to repair a torn rotator cuff or relocate a dislocated shoulder. Degenerative joint disease is age-related osteoarthritis more common in older adults.

In order to come to this conclusion, surgeons from the Department of Orthopedics and Sports Medicine at the University of Washington in Seattle took a look at the results of over 1000 patients treated with shoulder replacements. The procedures were all done by one surgeon over a period of 10 years. It’s common knowledge from many other studies that outcomes are different based on age. The researchers involved in this study knew from other studies that there have been numerous reasons proposed for these differences.

For example, maybe the younger patients went into the surgery with worse shoulder function compared with older adults and that made a difference in their final results. Some studies showed that women tend to report worse outcomes than men. Perhaps women just have a different idea of what is a successful surgery compared with men. Younger patients seem to have more complex pathologies (e.g., loss of blood to the joint, post-traumatic arthritis) compared with older adults. The vast majority of older adults who need a shoulder replacement suffer from osteoarthritis. These three potential causes for poor performance after total shoulder replacement (gender, level of perceived disability, and diagnosis) were the focus of this study.

So, which is it? Well, we spilled the beans right away by telling you it was the cause of the problem that was statistically linked to outcomes. There wasn’t a significant difference in results based on sex (male versus female) in either age group or comparing one age group to the other. The idea that maybe how the patient views his or her level of disability was a contributing factor didn’t pan out either. Patients on either side of the age of 50 (younger or older) tested out the same when given tests to self-assess disability.

The more complex pathologic problems suffered by younger patients appear to be the missing link. Levels of pain, discomfort, and function leading to patient dissatisfaction were more commonly reported in the younger folks. And that makes sense when taking into account the greater involvement of the surrounding soft tissues with capsulorraphy arthropathy that complicate the surgery and follow-up rehab program.

The authors do say that this was just one study looking at the patients of one surgeon. They didn’t look at all possible variables and factors. They focused on just the three mentioned. There are lots of ways adults with severe shoulder disability who are under 50 differ from adults with similar problems who are over 50. Even the surgical procedures could make a difference. Not everyone has the same operation or gets the same implant — even if the same surgeon does all the operations.

And let’s not forget the fact that younger patients are often much more active than older adults. The activity level alone could increase the risk of problems like implant loosening or debris collecting inside the implant from wear and tear. The authors also suggested it’s possible that younger adults have higher expectations so they rate their results lower than older adults would with the same results. And finally, younger adults have a longer period of time during which the implant can malfunction, deform, or create problems.

All in all, we really don’t have all the answers as to why younger adults don’t do as well as older adults after shoulder replacement surgery. But this study at least raises a few more questions and offers some evidence that the age factor may not be the real reason for differences in perceived outcomes. Further study and analysis like this one will help clear up this issue in time. Until then, each surgeon must make the best decision possible based on current evidence and individual patient differences and expectations. This should include age as well as other factors. Younger patients must be counseled as to the potential problems they may face postoperatively based on current research findings.

Orthopedic surgeons from Greece think they may have found a new way to quickly reduce an anterior shoulder dislocation with far less pain than two other methods commonly used. Reducing the shoulder joint simply means to put the head of the humerus (upper arm bone) back in the shoulder socket.

An anterior shoulder dislocation indicates that the head of the humerus has popped out of the socket in a forward direction. These injuries are most common with falls onto the extended arm/hand. Car accidents and sports activities are the two other ways in which this injury occurs.

The new technique is called the FARES method, which stands for fast, reliable, and safe. It is done with the patient lying on his or her back. The doctor faces the patient and holds the patient’s hand while the patient’s arm is down at his side. The elbow is straight and the thumb is pointing up. This position puts the forearm is in a neutral or midline position. A gentle traction force is placed on the hand to pull the arm down away from the patient’s head.

Then the arm is slowly moved away from the body, a movement called abduction. The clinician continues to pull the arm gently downward toward the feet while applying a vertical (up and down) oscillating movement. When the arm is abducted to about 90 degrees, the examiner gently rotates the patient’s arm into a position of external (outward) rotation. Now the palm is facing the ceiling.

The arm is gently pulled up toward the patient’s head with continued traction and oscillating motions. When the arm is abducted about 120 degrees away from the side of the body, the humeral head slips back into the socket and the shoulder is reduced.

In this study, they compared how well the FARES technique for anterior shoulder reduction compared with two other methods commonly used (the Hippocratic method and the Kocher method). Each of these other methods are similar to the FARES method but with slight differences.

Most of the time, one method works but sometimes the physician has to try a different approach. Each attempt to relocate the shoulder without doing surgery causes additional pain and apprehension on the part of the patient. The goal is to find the safest, easiest, most painless way to relocate a dislocated shoulder and avoid surgery whenever possible.

The Hippocratic method is done with the patient on his or her back. A sheet is placed around the patient’s chest and under the armpits. One person uses the sheet to apply traction toward the uninvolved shoulder. The other person applies a downward traction force to the dislocated arm while rotating the arm slightly.

The Kocher method is done with the elbow on the involved side in a flexed (bent) position (about 90 degrees of flexion). Instead of moving the arm away from the body, it is moved toward the body — a movement called adduction. The forearm is rotated outward as far as it will go comfortably (palm up). Then the arm is lifted up as far as it will go and the clinician internally rotates the arm until it reduces.

Patients in the study had their first anterior shoulder dislocation. They were divided into three groups based on assignment to one of the three reduction methods described. The maneuvers were done by first and second-year orthopedic surgery residents. All patients were awake and without sedation (medication to relax them or put them to sleep). The reduction procedures were done even if the shoulder was dislocated and there was a fracture of the greater tuberosity. The greater tuberosity is a bump on the head of the humerus where muscles attach.

The results were measured by 1) whether the first attempt was successful, 2) how long the reduction took to complete (in minutes), and 3) by using the visual analog scale (VAS) to measure patients’ pain levels during the reduction procedure. They found that the FARES method took half the time with much less pain.

For example, 88.7 per cent of the patients in the FARES group had a successful reduction. This compared with 72.5 per cent for the Hippocratic method and 68 per cent for the Kocher method. The time it took to reduce the dislocated shoulder using the FARE method ranged from slightly more than a minute up to three and a half minutes. The other two methods took at least two minutes (up to seven minutes) with quite a bit more pain reported by the patients.

The patients in this study who did not have a successful response to these techniques were taken to the operating room and sedated (put to sleep). While in this relaxed state without pain and without muscle guarding (tension), the same reduction method used in the clinic was repeated successfully in all cases.

The authors concluded that the FARES method of anterior shoulder dislocation reduction is safe and reliable while being faster and less painful than two other methods tested. The Kocher method was faster than the Hippocratic method but more painful for the patient. The FARES method can be done by medical students and residents who don’t have a lot of practice yet. It is a simple technique that can be done by one person. And it can be used without the expense of medications (pain relievers or muscle relaxers) or an operation.

More studies are needed to confirm these findings and to compare the FARES method of shoulder reduction with other techniques that were not considered in this study. As common as anterior shoulder dislocations are, finding the best method to reduce it that can be used in the emergency department or outpatient clinics is an important goal.

Adhesive capsulitis, otherwise known as frozen shoulder can be very painful and disabling, no matter what your culture or activities. In this study from South Korea, researchers compared the results of shoulder injection using two different methods. Change n pain, arm motion, and function such as eating with chopsticks, combing the hair, or using a computer were outcomes used to measure the results.

The treatment was an injection of a numbing agent (lidocaine) and triamcinolone (steroid) directly into the joint. Then each of the patients received five more (once a week) injections of sodium hyaluronate, a tissue lubricant to help the joint slide and glide more easily. There were two groups of patients all diagnosed with adhesive capsulitis matched by age, sex, affected side, and how long they had the symptoms of pain and loss of motion. After the first injection, the patients were all given instruction in some shoulder exercises to improve motion and mobility. The exercises were to be done at home every day.

The difference in treatment was in the way the injection was delivered. In one group, a doctor with seven years experience gave the injections by palpation (vision and touch to find the right spot). In the second group, ultrasound imaging was used to guide the needle into the joint. The physician using the ultrasound technique had two years of experience with this treatment approach. Ultrasound is replacing fluoroscopy (real-time 3-D imaging), which has been the preferred guidance system. But fluoroscopy is an X-ray technique that exposes the patient to radiation. So, the new and improved ultrasound machines now available may make it possible to replace fluoroscopy in this treatment.

The authors provided a detailed description of the technique used for both the blind (palpation-guided) and the ultrasonography-guided procedures. Patient position, arm position, type of equipment used, and type of needle and placement of needle are discussed. Photos of both techniques are provided. Before and after measurements were taken of pain levels, joint range-of-motion, and function. A special 10-function test previously published by K. H. Cho was used to assess function. Pain was rated for each of the 10 specific activities in the Cho test. The patients also completed the visual analog scale. (VAS), which is a measure of global (overall) pain.

If you thought the ultrasound-guided injections gave better results, you guessed right. But only for the first two weeks. Patients in the ultrasound group did report significant improvement in all areas. By the third week, the results evened out for the two groups and no further advantage was seen for the ultrasound-guided treatment group.

Patients in both groups continued to report decreased pain levels as the weeks went by. The ultrasound-guided group got the most relief early on with improved motion as well, but the final results were equal between the two groups. The same pattern was seen for shoulder/arm function — early improvements in the ultrasound group that were matched several weeks later in the blind-guided group.

How should these results be interpreted? The authors suggest that accuracy of injection makes the difference. In fact, previous studies comparing blind to ultrasound-guided injections showed a 33 to 46 per cent accuracy rate with blind injections but a 93 per cent accuracy rate with ultrasound-guided injections. It’s hard to argue with those kind of statistics.

And this study confirms that along with improved accuracy comes rapid improvement of symptoms. Patients with serious limitations in shoulder movement and function appreciate those kind of rapid results when it comes to quality of life issues such as getting dressed, getting back to work, and even being able to wipe the bottom after toileting.

The authors conclude that they will continue to follow a protocol of ultrasound-guided articular injections for patients with chronic adhesive capsulitis who have not responded well to conservative care. In their country, where national health insurance provides care for patients, cost is not a factor as it might be in the United States.

The suprascapular nerve along the back of the shoulder can get stretched or compressed enough to cause serious damage. This condition is called suprascapular neuropathy. The result can be shoulder pain and loss of function. For athletes who depend on the muscles supplied by that nerve, such a problem can be very disabling. Overhead athletes with traumatic shoulder injuries, especially severe rotator cuff tears seem to be affected most often.

In this review article, orthopedic surgeons from Rush University in Chicago report on their experience with this fairly uncommon shoulder problem. First, they review the anatomy of where the nerve is located, the two rotator cuff muscles it supplies motor function to (infraspinatus and supraspinatus), and what happens to cause suprascapular neuropathy.

Diagnosis depends on the patient history, physical exam, and imaging studies. Treatment can be conservative (nonoperative) with change in activity and physical therapy. Or surgery may be needed to remove bone, ligaments, or cysts putting pressure on the nerve. Repair of an insufficient rotator cuff is essential when weakness of this shoulder stabilizer alters shoulder biomechanics. For example, if the rotator cuff can’t stabilize the shoulder in the socket, then the altered position of the scapula and altered movement patterns of the scapula can pull on the nerve or compress (impinge) it.

Deciding what type of treatment is best requires an accurate diagnosis of the problem. Chronic pressure, traction, or kinking of the nerve can lead to denervation (destruction) of the nerve — and that means permanent loss of muscle strength and function supplied by the nerve. In cases like that, surgery is needed to remove whatever is putting pressure on the nerve, a procedure called decompression.

Sometimes the surgeon must also go in and open up a notch (opening) in the scapula (shoulder blade) where the nerve passes through. This notch or opening is called the spinoglenoid notch. Everyone has one and the natural size, shape, and location in the bone can vary. If the ligament across the top of this notch is tight and pressing down on the nerve and/or if the notch is too shallow or too small, the surgeon must make corrections in order to take pressure off the nerve.

The nerve can also get stuck to the bone by fibrous tissue so that it can’t move as the arm is raised. This condition is called nerve entrapment. Other things that can cause suprascapular nerve entrapment include bone fracture, cysts, and enlarged veins. Cysts form most often when damage to the labrum (rim of fibrous cartilage around the shoulder joint) allows fluid from the joint to escape and pool inside the cyst.

Drawings of the natural pathway for the nerve through this notch and down the back of the scapula are included in this article. Six different types and shapes of scapular notches are also drawn and depicted for the reader. Photographs of patients and cadavers help show what this condition looks like inside and out.

Besides hearing of a history of overhead work (either as a throwing athlete or as a manual laborer), the examiner will see muscle atrophy (wasting) along the back of the shoulder. Muscle strength will be weak when the patient tries to move the arm away from the body (a movement called shoulder abduction) or in external rotation. Most of the suprascapular nerve’s function is motor (moving the arm), but it serves a small sensory function (how the skin feels along the outside of the arm).

Suprascapular neuropathy can be difficult to diagnose. X-rays may be needed to look for fractures, unusual notch formation, and position of the humeral head in the shoulder socket as an indication of the integrity of the rotator cuff muscles. MRIs show the presence of any masses (tumors, cysts) and condition of the soft tissues (labrum, rotator cuff, muscle atrophy). An MRI can even show the nerve pathway and any areas of restriction. Special tests such as nerve conduction studies, electromyography (electrical study of muscle function), and injection of the notch can help pinpoint the location of nerve entrapment.

Unless there is imminent danger of permanent nerve damage, a conservative approach to treatment is tried first. Besides taking nonsteroidal antiinflammatory drugs (NSAIDs), the patient is referred to a physical therapist for a course of stretching and strengthening exercises to address any rotator cuff problems. Special neural mobilization techniques can also be done to restore full, free mobility of the nerve along its course.

How long should patients try a nonoperative approach to this problem? Who should go right to surgery and skip the conservative care? The authors suggest (based on studies and their own experience) that patients with suprascapular neuropathy from overuse do best with conservative care while those with structural causes of nerve compression should advance to surgery sooner than later. The risk of permanent nerve damage is greater when the symptoms have been present a long time (more than six months). Surgery is warranted if the surgeon is trying to prevent further nerve injury. Open and arthroscopic surgical techniques are discussed in detail.

No matter what kind of treatment is used, with nerve injuries, there is always the risk that full recovery will not occur. Patients may end up with muscle atrophy and weakness that just doesn’t go away even with exercise. Patients often automatically compensate for loss nerve function by using other nearby muscles to achieve motion previously provided by the affected infraspinatus and/or supraspinatus muscle. These persistent problems are reported in up to half of all cases. Fortunately, most are mild cases with significant pain relief making the surgery worth it.

The authors of this review on the shoulder took on a huge project with their research efforts with several goals in mind. First, they wanted to review and revise Codman’s table of shoulder abnormalities. Dr. Codman was the first to compile a list of signs and symptoms for each of over 25 possible conditions affecting the shoulder. Dr. Codman published this table in 1934 and it remains surprisingly accurate today. With the information collected at the Johns Hopkins Medical Center in Baltimore, Maryland, the authors were able to update the table and create a modern version of Codman’s table.

Second, they developed a database back in 1995 with information entered on all of their shoulder patients. The intent was to be able to compare results from before to after surgery. They also hoped to be able to study the data collected and look for patterns of clinical signs and symptoms that might help in diagnosing shoulder problems. They did this by comparing what they found during the preoperative history and exam with their actual findings at the time of the surgery. In this way, they could offer other orthopedic surgeons a summary of how useful are the various tests and measures in use today.

For the database, they collected measurements before, during, and after surgery. Some of the tests included joint range-of-motion, strength, information on general health, and specific provocative shoulder tests. Provocative tests apply load or force to various soft tissue structures of the shoulder to look for signs of damage or injury. Most of these tests are commonly used by orthopedic surgeons, physical therapists, and athletic trainers when assessing shoulder problems.

The reliability and validity of each test was measured for each of seven major conditions affecting the shoulder. The tests included range-of-motion, drop-arm sign, shoulder shrug sign, Neer Impingement sign, Hawkins-Kennedy sign, Speed test, Apprehension tests (anterior and posterior), compression test, lift-off test, painful arc sign, cross-body adduction test, resisted extension test, external rotation lag sign, and Whipple Test. So, you can see it was a very thorough collection of tests used in this field.

The authors provide five tables summarizing their findings for each of these tests. The tests were used with patients who had rotator cuff tears, shoulder arthritis, adhesive capsulitis (frozen shoulder), shoulder instability, labral tears, biceps disease, and arthritis of the acromioclavicular (AC) joint. The acromioclavicular joint is along the front of the shoulder where the clavicle (collar bone) meets the acromion. The acromion is a curved arch of bone over the top of the shoulder coming from the shoulder blade.

Third, they reviewed all the published studies on the shoulder including a wide range of diagnoses such as rotator cuff disease, tendon tears, shoulder instability, bursitis, labral tears, and joint abnormalities. Finally, they included a review of their own experiences examining, diagnosing, and treating complex and challenging shoulder problems. They offer the following observations: