News Category: Shoulder

The authors of this study report a definite benefit to shock wave therapy in the conservative (nonoperative) treatment of calcific (calcifying) tendinitis of the shoulder. That’s good news because this condition can affect up to 20 per cent of the adult population. And calcific tendinitis can cause debilitating shoulder pain — even leading to a frozen shoulder.

Calcific tendinitis is a disorder characterized by deposits of hydroxyapatite (a crystalline calcium phosphate) in any tendon of the body. Some people just refer to this as calcium deposits in the shoulder. The calcific deposits can be seen on X-ray as lumps or cloudy areas. That’s how the diagnosis is confirmed.

The tendons of the rotator cuff surrounding the shoulder are affected most often. Pain and inflammation result in loss of motion and function. Sometimes patients report shoulder stiffness or weakness. There may be a snapping or catching sensation during certain shoulder movements.

Treatment begins with antiinflammatories, steroid injections, and/or physical therapy. The condition is often self-limiting meaning it goes away or resolves on its own in time. Most patients are encouraged to stick with the treatment plan for six months. If, after six months, the pain isn’t reduced enough (or at all), then shock wave therapy called extracorporeal shock wave therapy (ECSW) may be considered. ECSW may be a good next step before thinking about surgery.

ECSW uses sound waves directed at the deposit. No one knows for sure how this works but it does seem to bring pain relief and the calcific deposit disappears on X-rays. It appears that the mass is broken up enough by the vibration of the sound waves that the body can then breakdown, liquefy, and absorb or resorb the fragments.

But there are many questions left hanging about this treatment. Who does it help? Is it safe and effective for everyone? What dose (pulses per session or number of sessions) gives the best results? Should high- or low- energy be used? Does it even matter?

By conducting a meta-analysis, the authors were able to answer two questions: 1) is it safe and effective? and 2) does the dose (high-versus-low) make a difference? A meta-analysis is done by reviewing all publications reporting on controlled trials of ECSW for calcific tendinitis of the shoulder.

Some studies compared patients who had ECSW with those who received no therapy, some other type of treatment, or a sham or placebo treatment. Sham or placebo means they thought they were getting the treatment but no sound waves were actually transmitted to the calcium deposits. There were also trials comparing shock wave therapy of different energy levels.

After comparing and analyzing all the data, they found that shock wave therapy was more effective than sham treatments or other therapy such as electrical stimulation. High-energy waves (0.2 mJ/mm2 or higher) worked faster and better in terms of pain reduction and calcium resorption.

Patients experienced a decrease in pain and improved function. And it appears that using high-energy shock waves was more important than the number of sessions. X-rays showed proof that the calcium deposits were disappearing.

It’s still not clear if patient selection is an important factor in the use of ECSW for calcific tendinitis of the shoulder. Future studies are needed to look into this variable as well as define the number of sessions needed for the fastest, most effective treatment of this condition. For now, it’s clear that ECSW is a safe and effective way to treat calcium deposits in the rotator cuff tendons. And it may help patients avoid having surgery.

Some shoulder problems are so complex and so difficult, it’s not even clear that surgery can help them. This may be the case with massive rotator cuff tears, shoulder instability, adhesive capsulitis (frozen shoulder), revision arthroscopic stabilization surgery, and other tendon injuries.

In this article, six orthopedic surgeons from around the world offer their opinions and expertise for these challenging conditions. Dr. Tonino from the United States, Dr. Gerber from Switzerland, Dr. Itoi from Japan, Dr. Porcellini from Italy, Dr. Sonnabend from New South Wales, and Dr. Walch from France offer insights, patient photos, and ideas for evaluation and treatment of these complex shoulder disorders.

Each patient must be examined and considered on an individual basis. Imaging studies such as MRI and arthroscopic exam help with the decision-making process, but the surgeon can’t just rely on the results of those tests to find the optimal treatment for each problem. It’s also important to consider why the patient has the problem in the first place.

For example, if there is a chronically dislocating shoulder, is it because a previous stabilization surgery failed? And if so, why did it fail? Were there surgical technical errors or other undetected injuries that affected the outcome? Was there some bony deformity, soft tissue imbalance, or other anatomical reason why this patient didn’t get a positive result from the previous surgical treatment?

If surgery is considered (perhaps for a severely frozen shoulder or massive rotator cuff tear), then the surgeon must put on his or her detective hat in making a preoperative assessment. Careful evaluation is needed of pain levels, shoulder motion, strength, and function before deciding on type of repair.

The surgeons say there’s no sense in attempting a repair of massive rotator cuff tears when the patient meets any of these three criteria:

You’ve probably seen a few folks along the way with a broken clavicle (collarbone). Most of the time, these injuries were left alone to heal on their own. Patients might have been given a sling to wear for a while. They were probably told what motions to avoid during the healing process. But that traditional view is no longer accepted. Now we know that these injuries occur on a continuum. Some people may need special care.

For example, not everyone gets better with conservative (nonoperative) care. Studies show that there’s a subgroup of patients for whom the results can be very unsatisfactory. The bone doesn’t heal, a problem called nonunion. In some cases, the bones knit together but not properly. This is called a malunion. In either case, the end result can be pain, decreased motion, and loss of shoulder function.

The authors of this article put together a detailed discussion of clavicle fractures. They gathered statistics from many other studies to highlight who is affected and what happens as a result of these injuries.

Several different classification schemes (e.g., Allman’s, Neer’s, and the Edinburgh classification) used by doctors to describe the type and severity are presented. Many drawings are provided to show various types of fractures. Some are undisplaced (broken bones do not separate or pull apart), displaced (two ends of bone shift apart), intra-articular (at the joint) or extra-articular (outside the joint). The fracture could be angulated, wedge-shaped, or comminuted (multiple fragments).

X-rays are used to identify the type of clavicular fracture. The surgeon performs a clinical exam to look for signs of damage to the nerves or blood vessels. If the fracture occurred as a result of trauma, there could be chest or rib injuries as well. Additional imaging studies with CT scans, MRIs, duplex scanning, or arteriography may be needed.

Once the diagnosis has been made, then the treatment plan is determined. The main decision is surgery or conservative care? Conservative care with a simple sling and activity modification is still good for some patients. The fracture heals well and the patient can slowly resume normal motion and activities.

But enough studies have been done in the past 10 years to support the need for surgery to stabilize the fracture. More cases of nonunion and poor outcomes have been reported with nonoperative treatment. Who should surgery be recommended for? And what should be done?

Once again, there’s enough new evidence to suggest that patients with displaced fractures are at increased risk for a poor outcome. This is especially true for displaced fractures with shortening of the bone. These patients can end up with shoulder weakness and decreased staying power (endurance) for activities requiring shoulder strength.

There are numerous ways the surgeon can approach the problem. A metal plate can be used along the top of the clavicle to hold things together while the bone heals. A newer invention is the site-specific precontoured locking plate. This plate was designed to remain inside the body (no removal required). It is less prominent (sticks up less) and can be used with older adults who have osteoporosis (brittle bones).

Sometimes the curved shape of the clavicle doesn’t allow the use of plates. The surgeon may have to use a nail or pin that is narrow and flexible enough to pass through the bone lengthwise. At the same time, it has to be strong enough to hold the bone together during healing despite forces placed upon it. This technique is called intramedullary fixation. The nails offer a minimally invasive way to treat patients who have many other injuries in the shoulder and arm.

Other techniques discussed by the authors include Kirschner wire fixation, coracoclavicular screw, plate and hook-plate fixation, and suture and sling ligament grafts. Some of these are used for specific types of fractures such as those that don’t heal and for patients who want to return to work or sports quickly.

All of these surgical techniques have their pros and cons. There are potential complications with each one. These include infection, plate failure, scar tissue formation, and implant loosening for starters. Other problems mentioned are nonunion of the bone despite fixation, refracture of the bone, and on more rare occasions, injury to the blood vessels during the procedure. Problems reported with intramedullary fixation include breakage, nerve damage, and skin breakdown where the pin enters the body.

Risk factors for nonunion must be taken into consideration. Older women with displaced or fragmented fractures have the highest rate of nonunion. Anyone with this type of fracture can end up with loss of shoulder motion, weakness, deformity, nerve damage, pain, and a clicking sensation in the shoulder. Daily activities are disrupted. They may be unable to sleep, drive, or engage in sexual activity because of pain and instability.

With each patient who needs surgery, the surgeon tries to find the right fixation device. The goal is to stabilize the fracture. They try to do this with an implant that’s too rigid. It’s best if some movement is allowed. If possible, the device selected is one that doesn’t have to be removed later, which would require a second surgery.

In the end, it simply isn’t possible to say what is the optimal or best treatment for each type of clavicular fracture that requires surgery. Specific guidelines just aren’t available yet. More studies are needed to help sort this out. Predicting which patients will have a good result with surgery (and what type of surgery to do) is not possible using any kind of formula or assessment tool yet.

It does appear that undisplaced clavicular fractures can be treated nonoperatively. In the case of displaced fractures, surgeons will continue to test out new and better ways to hold the fractured bone(s) in place until healing takes place. Review articles like this one will help everyone keep up with the latest information on this topic.

Young athletes are twice as likely to dislocate the shoulder compared to the general population. What’s the best way to approach this problem? When is surgery needed? These are just two of the many questions answered in this update on first-time shoulder dislocations.

The authors did not study a specific group of patients. Instead, they reviewed current information on pathoanatomy (what happens in the shoulder) and etiology (causes of dislocation). The need for a quick and accurate diagnosis that leads to a plan of care is established. The benefits of imaging studies are presented. And options for both conservative (nonoperative) care and surgical management are presented. Here’s a closer look at each of these topics.

Most first time shoulder dislocations are anterior (forward direction). The structures around the shoulder (e.g., ligaments, capsule, muscles) are designed to prevent dislocations. But with enough force and with the shoulder in just the right position, these safeguards can be overcome.

Younger patients are more likely to end up with a labral tear. Injury in older adults is more common because of degenerative changes of the rotator cuff associated with aging. The labrum is a tough rim of cartilage around the shoulder socket. The rotator cuff is a group of four muscles and tendons that surround the shoulder. Both of these anatomical structures help hold the shoulder stable and in place. A torn anterior-inferior (front/lower) labrum and joint capsule is called a Bankart lesion. Bankart lesions are very common in all anterior shoulder dislocations.

Most young athletes with their first shoulder dislocation are examined either on the field at the time of the injury or some time later in the emergency department. Some experts advise having an X-ray before trying to reduce the shoulder. Reduce means to put the shoulder back in the socket. Usually, the person is in so much pain, a closed (without surgery) reduction seems like the right thing to do. But there could be other injuries that need attention and that could be made worse by a closed reduction.

X-rays confirm the direction and severity of the dislocation. Any bone fractures present will show up on an X-ray. Other clinical tests may be performed to assess nerve, blood vessel, and soft tissue structures. If more details are needed, a CT scan and/or MRI may be ordered. MRIs with a dye injected into the joint can show the location and size of a labral tear.

Once the exam is completed, the surgeon can decide on the best plan of care for that patient. Reducing the dislocation is the first step. Sometmes this can be done without surgery. A special method called the Stimson technique can be used. A numbing agent is injected into the joint. Once the patient is pain free, he or she lies face down on an examining table. The injured arm hangs over the edge of the table. A weight tied to the forearm can pull the head of the humerus down, so it can pop back in the socket. In other cases, the patient may be anesthetized before closed (or open) reduction can be done.

Reducing the dislocation isn’t the end of it. The shoulder must be protected while the soft tissues are healing. If surgery isn’t needed to repair capsular tears, fractures, or a detached labrum, then immobilization in a sling for six weeks is still standard. This approach is more common with older,less active adults. Sports athletes who are at greater risk of recurrent dislocations may need arthroscopic repair.

When it’s early in the sports season, some athletes may opt for a modified treatment approach. A short period of immoblization, followed by an early program of range-of-motion exercises can ge them back in the game. in this approach, there is still a risk of recurrent dislocation(s), especially when the athlete is involved in collision or contact sports. And with each injury, the chances of more soft tissue damage are much greater.

Research is ongoing to find ways to prevent a second dislocation. Immobilizing the shoulder in a position of external (outward) rotation (instead of the traditional internal rotation with the arm across the abdomen) works much better. This is a fairly new discovery. Continued improvements over the years in surgical technique have helped reduce the number of recurrent dislocations. Debate continues about the best timing for the surgery.

Early repair may be best — before the damaged soft tissues stretch out and deform. As orthopedic surgeons, the authors describe their preferred arthroscopic surgical techniques and postoperative care for acute, first-time anterior shoulder dislocations. A procedure called the Bankart repair is done within two weeks’ time of the original injury. Post-operative rehab takes place in four phases. This model is based on animal studies showing how and when tendon-to-bone healing takes place.

Early movement is important to prevent scarring. Resistance must be avoided at first to prevent disruption of the healing site. Phase one takes place during the first six weeks. The focus is on reducing pain and increasing motion. During phase two (six to 12 weeks), full motion is restored before the strenghtening phase (12 to 20 weeks) can begin. In the final phase, the athlete is prepared for a return-to-sport with sports-specific exercises. This phase must be completed before contact sports are allowed again (usually between five to six months after surgery).

There is plenty of evidence that the approach to first-time anterior shoulder dislocations described in this article produces good results. Fewer recurrent dislocations and greater patient satisfaction have been reported. These are just guidelines. The surgeon must still make treatment decisions on an individual basis taking into consideration the patient’s age, type of sports involvement, and timing of the injury (preseason, during season, end of season).

If you want to know how experts with years of experience treat SLAP lesions, this is the article for you. SLAP stands for superior labrum, anterior and posterior. It refers to a torn rim of fibrous cartilage (the labrum) that edges the shoulder socket. The tear is at the top of the socket (that’s what superior means) and goes from the front (anterior) to the back (posterior) of the socket.

The authors (two sports medicine orthopedic surgeons) review how to evaluate and treat SLAP lesions. Knowing how the person injured him or herself is the first starting point. Overhead throwing athletes are the most likely people to develop a SLAP injury. That’s because the position of the arm when the injury occurs is flexion and abduction. This is the position pitchers or overhead throwing athletes are in just before moving the arm forward to release the ball.

The events leading up to the injury can be traumatic as in the case of repetitive overhead activity or falling on an outstretched arm. Or it could be degenerative. Degenerative SLAP lesions are more common in older adults as a result of the aging process. No matter what the cause, when a SLAP lesion occurs, the surgeon looks for other accompanying soft tissue injuries as well. This could be a rotator cuff tear, shoulder instability (a tendency to dislocate easily), or both.

There are different types of SLAP injuries labeled Type I, Type II, Types III, and Type IV. The exact type depends on whether the labrum is frayed along the edges, partially torn, or completely pulled away from the bone. Sometimes, the biceps tendon, which attaches along the upper front area of the socket is also pulled away. Labral tears may occur with or without biceps tendon disruption, which forms a separate classification or type of SLAP lesion. Two additional types (V and VI) have been named to include combined or complex SLAP lesions that aren’t fully described using I through IV.

Although the surgeon performs an examination of the shoulder and conducts numerous clinical tests, the exact lesion can’t be determined without imaging studies and arthroscopic exam. There are numerous tests designed to identify a SLAP lesion (e.g., active-compression test, compression-rotation or grind test, Speed’s test, the clunk test, the biceps load test and so on). It’s not necessary for the surgeon to perform all of these tests. Some are more reliable and sensitive than others.

Four of the more accurate tests are presented in this article. A description of each test along with photos of the examiner performing the test are included. Expected results for a positive response indicating a SLAP lesion are provided. The four tests include the (O’Brien) active-compression test, the compression rotation test, the pronated load test (a relatively new test), and the resisted supination external rotation test.

MRIs are still considered the gold standard in diagnostic imaging for SLAP lesions. There is debate about what type to order (contrast vs. noncontrast, type of view). The authors offer their own opinions. They suggest a high-resolution noncontrast MRI coronal sequence. The lesion can be seen as a cleft between the superior labrum and the glenoid (shoulder socket). MRI results are important before heading into the operating room. They show the full extent of the damage, which may not be as easily seen during the procedure.

Most SLAP lesions require surgery. But for a subgroup of patients with Type I lesions, conservative (nonoperative) care may be successful. This includes change in activity (no more throwing for a while), antiinflammatory drugs, and physical therapy. The therapist guides the patient through a process of reducing pain and restoring motion, strength, and normal movement patterns.

Who should have surgery then? The authors’ suggest anyone who has not obtained the desired results with conservative care, patients with a SLAP lesion and a major tear of the rotator cuff, and anyone with a large labral tear who has altered biomechanics (movement of the shoulder complex is no longer normal).

What does the surgeon do? Minor labral tears and frayed edges are shaved and/or smoothed back down. This procedure is called debridement. More severe tears are repaired. There are various ways to do the repair. These surgeons describe their method of establishing arthroscopic portals (where the needle is inserted into the joint), type and location of sutures and suture anchors, and method for making suture knots. Clear photos of each step are provided. Complex lesions requiring special surgical techniques are also discussed (including rotator cuff tears).

For the patient, the next step is a postoperative rehab program. The exact steps in this process are determined by the type of SLAP lesion, surgery that was done (e.g., debridement versus repair), and how much other damage was present. The postoperative rehab guidelines are provided in an easy-to-use table for the reader. These consist of movement, activities, and exercises performed during each of six phases from immediate post-op up to 24 weeks later. A short description of each phase along with any limited or prohibited motions is included.

What are the results of all this treatment? Well, that’s still a little bit up in the air. There aren’t very many long-term studies. What we have available so far shows good results in 75 to 90 per cent of the patients. Not everyone gets back to their preinjury level of shoulder function. Athletes who are not involved in overhead throwing seem to have the best chances for recovery.

For best results, the authors recommend a careful examination and accurate diagnosis. Follow-up therapy is essential (they say mandatory). Anyone having surgery must be aware of just how important their cooperation and compliance is in following the surgeon’s and the physical therapist’s directions.

Frozen shoulder is the layperson’s term for a medical condition called adhesive capsulitis. What is it? Well, the answer to that question is not entirely clear. There’s inflammation of the tissues in and around the shoulder joint that leads to fibrosis (scarring). The result is the joint gets stuck and can’t move smoothly anymore. Painful and limited shoulder motion are the two main characteristics of this condition.

What causes it? That’s not entirely clear either. Sometimes it just seems to come on without any reason. In other cases, it’s linked with diabetes, stroke, heart attack, or some other systemic illness. In this article, physical therapists review the condition and offer us some insights into what’s currently known about the pathology, diagnosis, treatment, and natural history. Natural history refers to what happens in this condition over time. For example, in many patients, it seems to clear up on it’s own over time.

There are different ways to classify or describe adhesive capsulitis. One method divides the condition into two separate categories: pimary (cause unknown) and secondary (linked with trauma or a systemic disorder). Patients with secondary frozen shoulder are further divided into two more groups based on which part of the joint is affected (intrinsic or inside the joint and extrinsic, which is outside the joint).

Physical therapists may use a different classification scheme altogether. This one is based on the patient’s irritability level (low, moderate, high). For example, someone with high irritability has pain that limits motion and function. Someone with low irritability may have slightly restricted motion with stiffness, but no pain. For patients with primary adhesive capsulitis, the natural history is one in which the patient begins with high irritability. As the condition gets better, the level of irritability goes down to moderate, and then low.

What’s happening inside the joint? In other words, what’s the pathologic process causing these symptoms? Here, there is more recent information to offer. New techniques of cellular analysis have shown scientists that there is both an active inflammatory process and chronic inflammation with the formation of fibrosis as an end-product. Yet in some patients, there’s no evidence of inflammation, but rather nerve cells are found inside the joint.

Surgeons can attest to the fact that there’s definitely scarring in and around the joint. They see it when they do open incision or closed arthroscopic surgery. Surgically releasing the fibrotic tissue restores motion immediately. Sometimes they see inflammation around the tendons and lining of the joint. Therapists perform stretching and joint mobilization to help these patients.

What’s the natural history of adhesive capsulitis? Experts differ on how they view this. Some say it occurs in three stages, while others see four distinct stages. Either way it’s described, there’s an initial period of pain, then stiffness (the frozen part), then recovery or the thawing phase. Sometimes the stiff, frozen stage is divided into the process of freezing and then the frozen phase.

Because the condition gradually gets better, it is considered self-limiting. The whole process takes anywhere from 12 to 18 months to go through the main stages. But at least half of the patients say they still have stiffness and loss of motion for years. So, what can be done about this condition? And what works best?

Many studies have been done looking at various types of nonoperative treatments such as acupuncture, nerve blocks, steroid injections, joint mobilization and/or manipulation, exercise, and antiinflammatory drugs. It’s difficult to compare and summarize the results because each study was done with different tests, measures, and definitions of treatment success. Is success measured by the return of full, normal motion? Is that even reasonable for this condition? It may be more realistic to see if patients end up with improved, but functional motion.

If patients get better in a year’s time, is treatment even needed? If treatment is provided, when’s the best time for it? Is there some point in time when antiinflammatories work best (or better than other choices)? If physical therapy is the treatment of choice, how often should the patient see the therapist? What treatment techniques should the therapist use? Is it the same for each patient? There are many unanswered questions yet to be studied.

At the very least, it’s clear that teaching the patient about the process and what to expect is important. They should be prepared for the fact that this is not a quick and easy problem to solve. A couple of Advil and a few exercises aren’t the answer. A consistent, daily program of exercises to relieve symptoms and restore motion is important — especially during the phase when increased blood supply to the area in response to pain sets up a fibrosis response (scar tissue formation). These fibrovascular inflammatory soft tissue changes are present in all patients with rotator cuff injuries linked with adhesive capsulitis.

Muscles stretch easier when they are warmed up. So, before starting a program of flexibility exercises, patients are encouraged to apply some form of moist heat before and during stretching. The therapist will help each patient determine how to stretch in a way that won’t overload the tissues and cause increased irritability. Frequency, intensity, and duration of exercise are calculated based on the patient’s irritability classification.

Assessment of irritability for classification purposes starts with a sleep history. Can the patient sleep through the night? Can the patient lie on that side and for how long? Both of these measures are indicators of irritability. A second way to determine level of irritability is to see if the primary problem is pain or stiffness. Stiffness is a sign of fibrosis. Pain is an indication that there is the fibrovascular inflammatory process going on. And finally, is the patient getting better, staying the same, or getting worse? Knowing how irritated the tissues are helps the therapist plan patient care.

The authors provide some detailed guidelines for how exercises should be done based on the patient’s irritability classification. For example, if the goal is to change how the joint perceives input, then low-intensity, short-duration range-of-motion may be best. The result will be to decrease pain and muscle guarding with the net effect of increasing shoulder and arm motion. A very helpful table outlining treatment strategies for each level of irritability is provided.

Since this is an article written by physical therapists, the discussion of how to perform exercises for each irritability level is a major focus. This approach may be new to some people who have never heard of it before. What works and doesn’t work seems to parallel what’s happening at the cellular level of the connective tissue during each phase from freezing to frozen to thawing. Studies show that too much stretching too soon in the process can result in worse results.

Evidence from research on the role of joint mobilization is also presented. Joint mobilization is a way to move the joint surfaces to increase motion. The technique involves some sliding and gliding of the shoulder joint in a variety of different directions. Which way to go is determined by areas of movement restriction. All joint mobilizations are followed up with an active home program of stretching. Although joint mobilization has some positive benefits, it’s not clear that this treatment technique is better than some other methods of working with the patient.

If the proposed rehabilitation program using levels of irritability as a guideline fails to improve patient symptoms to his or her satisfaction, then surgery may be advised. Under anesthesia, the surgeon may manipulate (move) the shoulder. With the muscles around the shoulder completely relaxed, the surgeon can put the shoulder through its full range-of-motion, breaking any adhesions present in all directions.

There are some potential problems with manipulation such as fractures or dislocations. It’s not a good procedure for anyone with bone loss or who can’t perform the necessary follow-up program of exercises. Open incision surgery isn’t really done on a frozen shoulder. The surgeon may go into the joint using an arthroscope and release the joint capsule This isn’t always the best option since bleeding into the joint from this procedure can cause the formation of more scar tissue.

When we step back and look at all the research that’s been done with short- to long-term results reported, it’s still not entirely clear what approach or approaches works best. Most patients get the best results in the first three months no matter what kind of treatment is applied. Steroid injections seem to have a good benefit in the first three weeks. It’s likely that pain relief early on allows the patient to move the shoulder and thereby regain range of motion and function quickly.

Should everyone have these injections routinely to speed up recovery and reduce overall costs? Probably not. A more common sense approach would be to save steroid injections for patients who don’t show improvement (or who continue to get worse) after the first three weeks even with physical therapy.

The authors conclude that despite the fact that adhesive capsulitis is a fairly common problem, there isn’t a clear path in treatment to help the patient recover. Using a rehab program based on levels of irritability applies the right amount of stress on the soft tissues of the shoulder while stretching the same tissues. Patients can be taught how to do these exercises at home for the long duration of the problem. The result hoped for is reduced pain, improved movement, and return of function. With satisfactory results from this type of program, patients may not have to have surgery.

When it comes to rotator cuff tears and repairs, things are shifting in the orthopedic world. Surgeons are gradually moving from an all-open incision procedure to an all-closed arthroscopic operation. And along with it, physical therapists (PTs) are modifying the rehab program to match each patient’s needs.

Patient goals in having a rotator cuff repair are to get rid of pain, increase motion and strength, and improve function. The surgeon’s goals are to gain high fixation strength (tendon-to-bone), reduce the gap between the torn tendon and bone, and restore mechanical stability of the shoulder. That means there has to be good healing of the tendon-to-bone that has the ability to hold up under repetitive load and force.

Results of surgery depend on two things: good surgical repair and a surgery-specific rotator cuff rehab program. That means more than ever, PTs and orthopedic surgeons must be communicating with one another about what kind of surgery was done, what the patient needs, and the best way to approach functional rehabilitation.

So, in this article, PTs and surgeons present information from both sides. The surgeons describe and discuss the three most likely types of rotator cuff repair techniques. These include 1) open rotator cuff repair, 2) mini-open rotator cuff repair, and 3) all-arthroscopic rotator cuff repair. A step-by-step summary of each procedure with photos of the incision site and size are included.

The open-incision repair is used most often for large rotator cuff tears that leave the patient with significant scarring and adhesions in and around the joint. The torn tendon has retracted or pulled back into the soft tissues and is not easily retrieved or repaired arthroscopically.

The major downside of this procedure is postoperative pain and the loss of muscle function because the deltoid muscle is cut to gain access to the damage. The pain can especially hinder progress in physical therapy. Slower recovery time is required.

The mini-open repair uses arthroscopy to avoid cutting the deltoid muscle. The incision is slightly longer than with all-arthroscopic repair but shorter than the full open-repair incision. The surgeon can split the deltoid rather than cut it and insert the scope down between the two halves of the muscle. The repair procedure can be completed arthroscopically from there.

Studies show that the results of the mini-open repair are similar to an open repair with up to 88 per cent of patients getting good-to-excellent long-term results. And finally, the all-arthroscopic repair is presented with some concerns about the procedure.

Surgeons say that there are fewer cases of stiffness and infection with this surgical approach. But there aren’t very many long-term studies to show how useful this method may be. And surgeons are still debating the best way to reattach the tendon to the bone arthroscopically.

Most recently, a new technique called double-row sutures has been developed. This technique secures a larger area of the tendon down to the bone. This repair method may make it easier to begin rehab earlier and move it along faster. Double-row sutures may help with the need to move the joint to avoid stiffness without disrupting the healing process.

But the bulk of this article is focused on the postoperative rehabilitation program following surgical treatment of rotator cuff tears. Patient education is important. Healing is slow. The patient must protect the repair site for at least 12 weeks. A special splint called an abduction pillow brace is used. The device fits under the arm. It is designed to place the shoulder in a protective position that avoids strain on the healing rotator cuff.

The authors point out 12 important factors that affect the postoperative rehab program. These include characteristics of the tear (size, location, tissue quality) and many surgical factors (approach, timing, and fixation method). Patient characteristics and access to care can make a big difference. For example, smokers in poor health have greater risks for poor wound healing. Access to a supervised physical therapy versus an independent home program can affect the final outcomes, too.

Therapists know that patients who have an open incision approach must be treated differently than an all-arthroscopic procedure. The difference comes back to the fact that the deltoid muscle is cut in a traditional open rotator cuff repair. For example, the patient must avoid contracting the deltoid muscle for up to eight weeks. It takes a full month longer for patients with an open-incision to regain their previous level of activity compared with even the mini-open repair.

The rehab program moves along at a pace that is directly linked with the size of the tear. Larger tears with more tissue damage and greater retraction of the tendon take longer to rehab. A more conservative approach is used.

The surgeon must let the therapist know the condition of the tear at the time of the surgery. Where was it located? How large was the tear and in which direction? Was it L-shaped, U-shaped, or crescent-shaped? What fixation method did the surgeon use to repair the tear (single-row sutures, double-row sutures, suture bridge)? The rehab timeline can then be matched to small, medium, and large tears. This is called surgery-specific rehabilitation.

If more than one part of the rotator cuff is damaged, then more protection and a longer recovery period are allowed. The therapist must know if the anterior (front of the) rotator cuff, the posterior (back of the) rotator cuff, or both were damaged. This information is used to restrict or encourage direction and degree of shoulder range-of-motion and strengthening.

Patients with traumatic (as opposed to wear and tear or degenerative) injuries tend to develop more stiffness postoperatively if they aren’t treated more aggressively right from the start. Early repairs after the injury can be moved through therapy more rapidly. But patients with fair-to-poor quality of tissue require a slower, more cautious approach.

Other factors therapists take into consideration when planning and carrying out a rehab program include which arm was affected (dominant versus nondominant), general health, smoking history, work status, and patient goals for return to sports or recreational activities.

The physical therapists involved in co-authoring this article present some specific guidelines for therapists working with patients who have had a rotator cuff tear repair. Tips on how to introduce range-of-motion exercises to avoid stiffness without endangering the repair are offered. The same is done for muscle retraining and strengthening exercises. Some of the suggestions were based on previous studies published. Others provided are the result of years of clinical experience.

Rhythmic stabilization exercises are used to activate the rotator cuff muscles but without actually strengthening the muscles. This is a safe and effective way to restore dynamic stabilization of the joint. Positioning and amount of force needed to achieve this result are described.

The authors also provide four very nice tables in the appendix to guide the therapist in planning an appropriate rotator cuff repair rehabilitation program. As already mentioned, the first table shows the patient, surgical, and physician factors affecting the postoperative rehab program.

The next two tables outline specific precautions, goals, and activities allowed day-by-day and week-by-week for small-to-medium tears and also for medium-to-large tears. Four phases are included from immediately after surgery all the way up to returning the patient to full work and sports activities.

And finally, range-of-motion and strengthening exercises with diagrams and descriptions are provided. These can be given to patients with space left for the therapist to record number of repetitions and how long to hold each exercise.

Hip and knee joint replacements have been around long enough now to have the results of long-term studies. But total shoulder replacements (TSR) are still new enough that the first 10- to 15-year follow-up studies are just coming out. In this report, surgeons from the Rochester, Minnesota Mayo Clinic present the longest duration study on shoulders with cemented metal-backed glenoid components.

Every joint replacement has two sides. In the case of the shoulder, there’s the humeral component to replace the round head of the upper arm bone (the humerus). And there’s the socket or glenoid side of the joint. The socket replacement can be made of all plastic called polyethylene, all metal, or a combination of both. The implants can be press-fitted (pressed into the bone without cement) or cemented in place.

The 100 patients in this study all received a cemented Neer-II metal-backed component (manufactured by Kirschner Medical in New Jersey). The patients were carefully selected for the study. They had to have a diagnosis of osteoporosis without a history of trauma. Follow-up had to be for at least two years. Anyone with a different kind of glenoid implant was not included in the study.

There is no real guideline for when to use the Neer-II metal-backed component. Studies have not shown one implant type has an advantage over the others. Some surgeons choose the metal-backed implant for patients who are large. The reason for this is because the metal-backed component is larger than the all-polyethylene implant. Smaller patients are given the all-polyethylene part because it is smaller and fits better.

The Mayo has a unique advantage in doing studies like this. They have a large number of patients whose information has been downloaded into their computer. Researchers can use the computer database to pull up specific patients and pertinent information.

In this case, all the computer files of patients who had a shoulder joint replacement could be collected. If the patients met the study criteria, then they received several surveys to fill out. Records on range-of-motion before and after the procedure were checked. And the results of X-rays were also included.

The outcome measures used to determine results included pain, shoulder range-of-motion, and function. Function was assessed based on a combination of pain, motion, and activity level. Activity was usually limited by the presence of pain and loss of motion. X-rays were examined by two independent shoulder surgeons. They didn’t know the patients what the patients looked like clinically.

Suspicious or alarming X-rays findings included periprosthetic lucency (thinning of the bone around the implant), subluxation (partial dislocation of the implant), and erosion (wearing away) of the bone underneath the implant.

There were some complications that required a revision procedure. Loosening of the implant was the biggest problem. Other problems included polyethylene wear and bone fracture of the humerus (upper arm bone). The biggest concern was for the high rate of periprosthetic lucency.

Anyone with subluxation had decreased and painful motion. There were no such symptoms with bone changes (erosion or lucency). Patient results were rated as excellent in about half the group. The remaining half alternated between satisfactory and unsatisfactory in rating their results.

Most of the unhappiness with the outcomes were related to a loss of motion, presence of pain, or need for revision surgery. Men and women responded the same to questions about satisfaction, so the results weren’t linked with gender (male versus female).

The main author of this study had previously done a study on patients receiving an all-polyethylene glenoid implant. The results of those patients were also compared to these patients. There was no indication that one type (polyethylene versus metal) was better than the other.

Most studies end the report by giving a list of limitations with the study. There were quite a few possible problem areas with this study. These limitations can sometimes affect how reliable or valid the study results are.

For example, there were three shoulder surgeons involved instead of one surgeon doing all the procedures in a consistent way. And even though patients with rotator cuff tears were screened out, there were still a few that were discovered at the time of surgery. The presence of a rotator cuff tear changes how the surgery is done.

Follow-up with X-rays wasn’t always possible for patients who had moved or died. Range-of-motion was measured by different surgeons (again, instead of one surgeon consistently measuring everyone). And they did not use a special tool called a goniometer to get objective motion readings. And there wasn’t consistency in deciding which patients should get the metal-backed implant.

But despite all the ifs, ands, or buts, the results represent an important step forward in tracking the results of shoulder replacement surgery using a specific component part. The authors suggest further follow-up is needed and especially further study on why there was such a high rate of bone lucency (thinning) around the implant in so many patients. For now, it can be said that using the cemented metal-backed glenoid implant provides pain relief and improved motion for patients with osteoarthritis.

With any new surgical procedure developed, there can be problems. In this case, we are talking about shoulder replacement surgery that fails due to fracture or bone loss. Treatment options are limited. Surgeons are looking for ways to change that.

In this study, surgeons from the Florida Orthopaedic Institute (Tampa) report on an expanded study they started several years ago. Patients in the first study (90 adults) received a reverse shoulder prosthesis. Twenty-five (25) of those patients were in this current study.

A reverse shoulder implant places a glenosphere (round ball component) where the shoulder socket used to be and a cup-shaped implant at the top of the humerus (upper arm bone). In the first study, this type of implant was used because the patients had a traditional shoulder replacement that failed. The pain and dysfunction were too great to just leave the original implant in place.

The 25 patients in the second study had additional problems to be solved. They had the reverse shoulder procedure as described, but ended up with bone loss at the top of the humerus. Major bone loss occurs when the first implant is removed. This in turn caused shoulder instability from deficiency of the rotator cuff (muscles that hold the shoulder in place). They had all tried conservative (nonoperative) care, but it didn’t help.

So, the surgeons used a special allograft (bone graft donated from a bone bank) attached with cables to the proximal (upper area of the) humerus. That sounds simple enough. But the procedure requires the surgeon to measure how much bone loss is present in order to determine the size and shape of the bone graft needed. And just the right amount of tension must be created using the bone graft to restore correct orientation of the prosthesis stem inside the humerus.

The patients all had a deficient rotator cuff because of the bone loss. When bone loss extends past where the muscles normally attach, the muscles become weak and cannot contract normally. That complicates matters because without the muscles to provide tension, the biomechanics of the shoulder are altered and shoulder instability becomes a problem. The allograft helps because it can be placed in such a way as to also improve tension from the deltoid muscle in the upper arm. The result is a stable shoulder once again.

The authors provide X-rays and photos to help guide the surgeon in understanding the procedure. Special X-ray views (e.g., Y lateral, rotation Grashey films) were used to see how much bone loss was present and to look for loosening of the implant stem inside the humerus. Subluxation (partial dislocation) of the humeral head was graded from zero (no subluxation) to three (more than 50 per cent subluxed).

Results of this restorative revision surgery were measured using X-rays, patient report of pain, shoulder range-of-motion, and function. Final X-rays taken in the study were used to look for subluxation, broken hardware, or loosening of any of the component parts.

They were also able to assess how well the graft had been incorporated using the same follow-up X-rays. They could tell the graft had taken or become one with the host bone when the junction line between the host and the graft was no longer visible. Loss of graft bone (called resorption) could be measured by comparing X-rays taken right after surgery (with the implant newly installed) with X-rays taken later during the follow-up period.

The procedure was successful for three-fourths of the group. They were satisfied with the results and rated their improved motion and function as good-to-excellent. Videos and range-of-motion measurements taken of the patients before and after the revision surgery confirmed the patients’ reports of improvements.

The remaining patients had complications such as infection, dislocation, fracture, and instability. Some could be treated conservatively, while others required another revision surgery. Each patient was treated individually according to the problem present and with the best treatment option available at the time.

The authors conclude that when a reverse shoulder procedure is done after a failed shoulder replacement and bone loss results, all is not lost. The allograft-prosthesis approach described in this study can save the joint, reduce pain, and preserve function. This type of shoulder reconstruction requires considerable experience on the part of the orthopedic surgeon.

Although the results of this study show promise for this salvage technique, it remains to be seen how it holds up in the long-run. The patients will be followed and long-term results reported sometime later.

Many people, especially athletes, are familiar with the term shoulder separation. In medical terms, it’s called an acromioclavicular or AC joint injury. The joint is located along the front of the shoulder where the clavicle (collar bone) meets the acromion (the bone that comes across the top of the shoulder from off the shoulder blade).

When the injury is severe enough, not only does the AC joint separate, but other damage can occur in and around the joint, too. That’s the topic of this article. How often do these associated shoulder injuries occur? What type of injuries are they?

AC joint separation or dislocation is the result of direct trauma (usually from a fall) on the shoulder or arm when it is next to the body. Alternately, falling on an outstretched hand or elbow can cause the same injury. The mechanism is more indirect as force through the hand or elbow transfers to the shoulder. With enough force, the head of the humerus is pushed upward — right into the acromion.

The majority of injuries occur during activities such as bike accidents, skiing or snowboarding, and other types of falls. Other activities leading to AC joint dislocation include soccer, motorcycle accidents, ice hockey, judo accidents, or horseback riding injuries.

It’s not uncommon for the associated injuries to be missed at the time of the diagnosis for AC joint separation. The patient’s shoulder is painful and range-of-motion is limited. So clinical testing is also limited. Without an arthroscopic exam, no one knows there are other problems. But once the AC joint has been treated, the patient with continued shoulder pain may need a second look.

Patients with severe AC joint separation may be spared the delay in recovery with early diagnosis of any associated injuries. In this study, preoperative testing for the presence of associated shoulder injuries was performed in cases of more severe AC separations (grade III through V). A special set of X-rays was taken called a trauma series. During the surgical procedure to repair the AC joint separation, the surgeon examined the joint carefully for other types of injuries.

Of the 77 patients tested, 18 per cent had intra-articular (inside the joint) injuries. Most of those injuries were superior labral anterior posterior (SLAP) lesions. Rotator cuff tears and fractures were the other most common types of intra-articular injuries.

A SLAP lesion refers to a tear along the entire upper surface of the labrum (fibrocartilage rim around the shoulder socket). Only the most severe type of AC joint dislocation (Type V) had a SLAP lesion. And only one of those SLAP lesions in this study was severe. All injuries (including the SLAP lesions) were repaired during the surgery to reconstruct the AC joint. The authors provide detailed descriptions of the surgeries performed.

The authors conclude that all patients with AC joint injuries should be evaluated carefully for additional injuries. Any force strong enough to dislocate the AC joint is often strong enough to damage other areas as well. MRIs may be useful but the most sensitive and specific test for this problem is arthroscopy.

Anyone with a high grade AC joint injury who continues to experience pain and loss of motion after surgical treatment should be further evaluated. The surgeon should look for the presence of other intra-articular injuries, especially labral tears, rotator cuff tears, and fractures. Post-operative MRIs using an intra-articular contrast dye give the best information. MRIs aren’t needed when the surgeon assesses the entire shoulder complex arthroscopically in the acute phase.

Shoulder replacement or arthroplasty is not unusual anymore. Regular replacements of the ball and socket joint are often done for patients with painful and limited range of motion. But the standard shoulder replacement isn’t the best choice for some people. Some patients need a reverse shoulder arthroplasty (RSA). This is mostly used for people who have injuries of the rotator cuff and shoulder arthritis that leave the shoulder unstable.

Reverse replacements put the ball of the joint just off the shoulder blade with the socket off the upper arm. This placement is different from the usual ball at the top of the humerus (upper arm bone) and the socket on the shoulder blade.

The reverse shoulder joint isn’t a perfect solution. It comes with problems of its own. For example, some patients end up with pain, loss of motion, and a problem called impingement. Impingement results in an inability to put the arm all the way down at the side. The implant design, location, and angle result in the two parts of the implant bumping up against each other, preventing full motion.

Specifically, the medial (inside) edge of the socket (now located at the top of the humerus) bumps up against the lateral outside edge of the scapula (shoulder blade) where the new round ball (glenosphere) is located. This creates a problem called scapular notching. Depending on the location of the glenosphere, motion can range from zero degrees (no impingement) up to 38 degrees of impingement (in other words, the arm is 38 degrees away from the body).

When reverse shoulder replacements were first introduced, the glenosphere was placed in the middle of the glenoid (anatomic shoulder socket). But problems developed and surgeons recognized the benefit of changing their surgical technique to avoid those complications. Despite changes made, scapular notching was still a problem.

In this study, investigators at the Florida Orthopaedic Institute Research Foundation study ways to place the implant to minimize the chances of developing abduction impingement. They did this using a computer-simulated program. The program allowed them to try various angles and positions of the glenosphere and then check to see if impingement occurred and by how much.

The authors divide the factors affecting impingement into two groups. The first group was surgical factors. These included location and tilt of the glenosphere (where and how it is implanted on the scapula). The second group was implant-factors such as size, center-of-rotation, and humeral neck-to-shaft angle. Placing the glenosphere further out of the bone changed the center-of-rotation. This is called offsetting.

The authors were able to run hundreds of simulated combinations of these factors. They used three different center-of-rotation offsets, three glenosphere sizes, and three different humeral neck-shaft angles. They ran all of the tests with two different glenosphere positions: superior (implanted up higher in the scapula) and inferior (placed down lower in the scapula). They were able to measure how much impingement changed with small changes in conditions.

In this way, they could figure out which factor or variable had the most effect on impingement and by how much (measured by degrees of motion). They found that an inferior placement of the glenosphere with a lateral offset gave the best result with minimal (or no) impingement. The greatest amount of impingement (38 degrees) occurred with a superior position of the glenosphere and no offset.

By playing with the amount of offset (zero, five millimeters, or 10 millimeters), they were able to find that motion was best with a five- or 10-millimeter offset and using an inferior position of the glenosphere. Glenosphere tilt, humeral neck-shaft angle, and implant size had less of an effect on impingement.

Prosthetic size seemed to have the least effect on impingement. Motion was greatest when the largest implant size was used. Abduction (moving the arm away from the body) and adduction motion (bringing the arm next to the side) was best with a 150-degree neck-shaft angle.

The authors set out to find ways to improve the surgical technique and implant design for the reverse shoulder replacement procedure. The goal was to improve range-of-motion and limit impingement. Ideally, they wanted to eliminate the scapular notching that prevents patients from resting their involved arm down alongside the body.

The surgeon won’t always be able to follow the guidelines set out here because of individual patient factors. Poor bone quality, frayed soft tissues, and muscle strength or muscle imbalances can force the surgeon to make other choices than what is recommended here. Variations in normal anatomy may also redirect the surgeon. Whenever there is a choice, these changes in surgical technique can be used to provide positive patient outcomes with improved motion, reduced pain, and increased function.

What happens to athletes who injure their shoulder and end up with a shoulder separation? Acromioclavicular (AC) joint separation occurs in almost 10 per cent of athletes who suffer some type of shoulder injury. The most common mechanism for an AC separation is a hard fall directly on the shoulder with the arm next to the body.

The AC joint is part of the shoulder complex. The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone). The connection between the scapula and the clavicle is the AC joint.

To be a little more specific, the part of the scapula that makes up the top of the shoulder is called the acromion. The AC joint is where the acromion and the clavicle meet. Ligaments hold these two bones together.

AC joint separations are graded from mild to severe, depending on which ligaments are sprained or torn. The mildest type of injury is a simple sprain of the AC ligaments. Doctors call this a grade I injury. A grade II AC separation involves a tear of the AC ligaments and a sprain of the coracoclavicular ligaments. A complete tear of the AC ligaments and the coracoclavicular ligaments is a grade III AC separation. This injury results in the obvious bump on the shoulder.

Only patients with Type I or II were included in this study. These represent the more mild cases of AC disruption. More severe cases are more likely to have surgical care. Twenty-three (23) patients treated with conservative (nonoperative) care were followed for 10 years to see how they fared. There’s always been a question about how these shoulders hold up over the years without surgery to repair the ligamentous and joint damage that occurs.

Conservative care included resting the arm in a sling, using ice, taking oral antiinflammatory drugs, and exercising. A specific rehab program under the direction of a physical therapist was prescribed. Patients were seen four to six weeks after the injury. Sessions were conducted for the next two to three weeks.

Most of the patients in this study were men. Everyone was tested using the Constant score, University of California-Los Angeles Shoulder Scale (UCLA), and the Simple Shoulder Test (SST). Both shoulders (involved side and uninjured side) were measured and compared. Ultrasound studies were used to measure the width of the joint separation. Joint displacement (distance from clavicle to acromion) was also measured.

Half the patients reported ongoing mild but persistent symptoms of pain and/or clicking of the AC joint. The symptoms were enough to interfere with functional activities but not enough to seek the services of a physician or therapist for follow-up treatment. The actual width of the separation did not seem to be linked with loss of shoulder function.

The authors sum up their findings by saying that what seem like minor shoulder injuries may not be as innocent as they first appear. The incidence of residual symptoms is fairly high. More than one-third of the patients with a Type I injury have ongoing symptoms years later. And patients with type II AC separation are twice as likely to have long-term symptoms as those with type I injuries.

One surprising finding was the comparison of the AC joint space from side-to-side. They expected to find that the injured joint would have a wider distance between the two joint surfaces. What they actually found was the two sides (injured and uninjured) were very similar. And that was surprising because the AC joint usually narrows with aging and degeneration. It’s possible the group just wasn’t old enough to register this type of change yet. Another 10 years might be more telling.

Rotator cuff injuries are not uncommon and they don’t happen in only athletes. Anyone can tear their rotator cuff, which is a group of four muscles and several tendons around the top of the humerus, the bone that connects the arm to the shoulder. Although some people with torn rotator cuffs have a lot of pain, researchers estimate that as many as 50 percent of people over the age of 60 who have this injury are asymptomatic, they don’t feel it.

In younger people, a torn cuff is usually caused by heaving lifting or manual labor and it causes quite a bit of pain, making it difficult to use the affected arm. As a result, the person who is injured may find it hard to work, resulting in cost for medical care and lost work time. A massive rotator cuff tear is defined as there being two or more tendons that are injured. These are particularly hard to treat and can often be retorn after repair, more so than after smaller tears are repaired.

The authors of this study followed 27 patients who had massive rotator cuff repairs to see what their outcome was. The researchers assessed how well they were doing a few years after the study and checked in again about nine to ten years after. Since four patients were lost to follow-up, the final results included 23 patients. All the patients had undergone an open rotator cuff repair and then wore a sling and splint. They were given passive exercises under the supervision of a physiotherapist. The patients were only allowed to do active exercises after six weeks, followed by strengthening exercises six week later.

The 23 patients, who were on average 54 years old, were examined using the same types of x-rays, magnetic resonance imaging, as well as other tests that were done earlier at three years follow up. The researchers found that there were no complications or repeat surgeries in the period between the 3-year and the 9-year follow up. At the final follow up, 74 percent of the patients said that they were very satisfied with the surgery and its results, 22 percent said they were satisfied, and one patient was disappointed in the results. This was a bit of a change from the 3-year follow up because two patients had rated themselves as satisfied then but very satisfied at nine years, three changed from disappointed to very satisfied at nine years, and one patient said they were satisfied first but this changed to unsatisfied.

One of the issues that the researchers wanted to examine was the retear rate, how many patients had retorn their rotator cuff. After almost 10 years, the retear rate was an average 57 percent. It was higher if the patient had torn three tendons, at 86 percent, and lower if there were two tears, at 44 percent. The researchers noted that none of the retears was bigger than the original tears. While it may seem that the number is high, especially when compared with studies that found there was an average 13 percent rate of retears in tears of only one tendon, this study’s finding is in line with others that examined the same problem. The authors pointed out that their findings differed from other studies in some ways. For example, in this study, there didn’t seem to be a relationship between the age of the patient and the likelihood of retears.

As with all studies, there were some limitations. The researchers in this study weren’t able to determine exactly when the retear occurred. The authors also pointed out that their study was relatively small and the patients were relatively young, which may have made an impact on the results.

The authors concluded that the open rotator cuff repair offered good results for at least 10 years following surgery although the chances of retears did increase over time.

Many studies have shown that patients hurt on-the-job and covered under Workers’ Compensation (WC) have worse results after rotator cuff repair compared to those who do not have WC claims. The reasons for this difference still aren’t clear.

In this study, researchers test individual factors to see if they could find a specific cause for the worse results in WC patients. The research method they used was a multivariable analysis. This statistical analysis helps show the effect of each factor studied while controlling for other factors that could confuse the results.

They did this by just studying patients treated by one single surgeon. This approach helps eliminate differences from one surgeon to another. Each patient had a full-thickness tear with symptoms lasting for more than three months despite conservative care. Rotator cuff repair was done using one of three surgical techniques (open repair, mini-open repair, arthroscopic repair). Patients were divided into two groups. The first group was Workers’ Compensation patients. The second group was non-Workers’ Compensation patients.

There were no noticeable differences between the two groups based on repair technique. Not everyone had the same exact surgery. Some patients had the rotator cuff repair plus adjunct (additional) repairs. Some of these surgeries included subacromial decompression (takes pressure off the rotator cuff), distal clavicular resection (removes end of collar bone; used for arthritis), and biceps tenodesis (repair torn biceps tendon). The authors reported no differences between the two groups as a result of these extra procedures.

Several other measures were taken before and after surgery to help identify factors that could explain the differences in results between WC patients and non-WC patients. Each patient was examined by the surgeon and gave a complete medical history. They also completed a series of questionnaires to assess pain level, function, expectations, general health, and psychosocial status.

The visual analog scale (VAS) was used for pain, disability, and quality of life. For each of these variables, the patient gives a rating from zero to 10. Zero means no pain, no disability, or no effect on health or happiness. Ten refers to severe pain, disability/unable to use the arm, and very bad problem.

Expectations of treatment were also measured using the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS). This survey asks patients what they expect in terms of symptom relief, comfort, sleep, activities and exercise, and function or disability. Expectations are scored from one to five. One is the lowest level of expectations and five is the highest level.

The Simple Shoulder Test (SST) and the Disabilities of the Arm, Shoulder, and Hand (DASH) are two well-known tests of specific limb function. Each patient completed these two tests as well. They were also given the Short Form-36 (SF-36), which is a measure of physical function, pain, general health, and social function. The SF-36 helps identify physical, emotional, social, and mental factors that might contribute to worse outcomes.

Besides completing these formal tests, patients were also asked about their use of tobacco and level of activity (retired, sedentary, light, strenuous). Any other health problems were recorded.

Everyone followed the same postoperative rehab program supervised by a physical therapist. There were some differences in the exercises and timing of activities based on whether the patient had a mini-open, open, or arthroscopic repair. For example, passivbe motion was more limited during the first four weeks for patients who had an arthroscopic repair versus an open repair.

After all the data was collected and carefully analyzed, the Workers’ Compensation group did have worse performance and worse improvement in all areas (compared to the non-WC group). When all other things are equal, the main difference was whether or not the patient had a WC claim. To put this in research terms, we would say that Workers’ Compensation status is an independent predictor of worse outcomes.

Sex, duration of symptoms, size of the rotator cuff tear, and number of other health problems did not seem to make a difference between the two groups. Everyone in both groups improved from before surgery to after surgery. But the general trend was for WC patients to have lower function on the SST and DASH tests. Level of pain and quality of life were worse for the WC patients. And they showed overall less improvement.

The WC group was younger, had lower educational levels, and fewer were married compared to the non WC group. But the multivariable analysis controlled for these differences and showed they had no effect on the results. That left the authors wondering what is it about being a WC claim patient that makes the difference?

They asked if it is the process of a WC claim that affects the outcome? Or is it something about the individual who files a WC claim that is the cause of a worse result? The WC group did have lower expectations but it wasn’t clear if that was the important factor. Maybe the lower expectations were related to the lower educational level in the WC group.

There is always the possibility that secondary gain is the underlying factor. Secondary gain refers to the patient’s hope of receiving a financial reward for his or her injury. This study did not assess that factor directly. Measuring results before and after the claim has been settled may help shed some light on the effect of secondary gain.

For now, the authors can only conclude that a WC claim had a negative effect on the short-term results of a rotator cuff repair. And they point out that there are other variables they didn’t test for. Further studies are needed to assess the effect of anatomic factors (tendon quality, repair strength). Long-term results of this study (five to 10 years later) may show that when it’s all said and done, outcomes are equal.

The shoulder is a well-used and important joint. It allows you to move your arm at will and then bears the weight of objects you pick up, as well as the weight of your arm if you are reaching up or beyond your immediate reach. Because of the way the shoulder joint performs, if a nerve is compressed, it can cause significant pain and weakness in your shoulder and/or arm. The area where the nerve is also affects how your arm will react, so it’s important that nerve compression of the shoulder be pinpointed and diagnosed as quickly as possible.

One type of nerve injury is called the suprascapular nerve impingement. Along the back of your neck runs the uppermost part of your spine. This is called the cervical spine and the vertebrae, the bones or discs that make up the spine, are numbered from C1 to C7, with C1 being the upper most and C7 being the last in this particular series. Nerves feed down the spine and branch out at the different vertebrael levels, with each level and nerves affecting a different part of the body. With suprascapular nerve impingement, the nerve that comes from between C5 and C6, which passes deep into the upper arm muscles and across the collarbone, is affected. Even this, however, has subsections that need to be diagnosed because there appears to be five different types according to the end location, called notches.

The two most common notches are the suprascapular notch and the spinoglenoid notch, usually caused by a narrowed tunnel though which the nerves pass, or some sort of blockage that presses on the nerves. The signs of these notches are shoulder pain in the back and side of the shoulder and perhaps difficulty raising your arm or turning it outwards (externally). If the pain has been around for a while, the muscles may start to atrophy, or waste away. When the doctor examines the shoulder, it may be tender and this tenderness may be relieved by an injection of anesthetic to the area.

To treat this, if there is no obvious reason causing the nerve pressure (seen by x-ray or further tests), there is no rush for surgery because there is nothing specific to work on. In this case, conservative management is usually the way to go. This may mean reducing the activity of the shoulder, using anti-inflammatory medications to help reduce swelling and relieve pain, and physiotherapy. If, after six months, there is no improvement, then it may be necessary for surgery. During the surgery, the surgeon relieves the compression from the nerve.

Another shoulder issue is called long thoracic nerve palsy, which comes from the C5, C6, and C7 area. The nerve passes the brachial plexus, a group of nerves that come from the neck and branch off to feed out to most of the nerves that control movement in your arm. The purpose of this nerve is to move the scapula, the bone at the back of your shoulder, as necessary.

If this area has become injured, it’s usually because of a blunt trauma to the area or if your neck is turned, with your head facing the other direction away and the shoulder is forced back in the opposite direction. Signs of this injury are usually pain underneath the scapula, difficulty raising the arm, and a popping or clicking sound coming from the scapula region when you try to lift your arm. The majority of patients recover without surgery, although it can take as long as two years for full recovery. To do this, the activity of the arm and shoulder must be limited for a while and exercises are important to maintain arm strength. If the problem isn’t resolved after a year, then surgery is usually the next choice.

Quadrilateral space syndrome is a condition where a nerve that comes up from behind the brachial plexus and provides sensation to the deltoid muscle and surrounding area is damaged. The deltoid is the muscle around the shoulder itself. If there is damage in that part, patients may complain of shoulder discomfort, not necessarily outright pain, especially when the shoulder is forward, with the arm raised. This injury is often found in adults between the ages of 20 ad 35 years and usually on the dominant hand.

Treatment for quadrilateral space syndrome is usually rest for the shoulder, anti-inflammatory medications to reduce any swelling and relieve pain, cortisone injections into the area, and physiotherapy. If, after six months, there is no improvement or not enough improvement, surgery may be the next step.

Finally, the last injury covered in this article is the thoracic outlet syndrome, which occurs in the area bordered by the first rib and the collarbone. If a patient has this problem, the signs are usually neck or shoulder pain and weakness of the arm on the hurt side. If the artery is being pressed upon, the arm may be painful and discolored, with it becoming pale after exercise. Rarely, a patient could have a stroke.

To diagnose this problem, doctors do a neurological (nerve) examination and see if they can reproduce the symptoms with certain techniques. X-rays are done to rule out other problems, as is an angiogram to see if there is any blockage in the artery. As with the other shoulder injuries, first treatment is conservative, to try to avoid the need for surgery. This means physiotherapy to improve the arm strength and body posture. This type of injury may require several months of treatment before any improvement is seen. However, if the treatment fails or there is a progressive worsening of symptoms, surgery may be done.

The authors of this study concluded that the various shoulder nerve syndromes can be quite similar in symptoms and in treatment, with surgery being the back up approach if conservative treatment is not effective.

There are some new studies on the condition commonly known as frozen shoulder. They have added information to what we know about how this condition develops and how to treat it. In this report, surgeons from the Hand and Upper Limb Centre in Ontario, Canada bring us up-to-date on this topic.

Frozen shoulder (also known as adhesive capsulitis) doesn’t show up on X-rays or ultrasound. But it causes enough pain, stiffness, and loss of shoulder motion that anyone who has had it knows it’s real. So, what’s causing it, and what can be done about it?

Changes in the synovium (fluid lubricating the joint) have been observed in adhesive capsulitis. This may occur without a known cause. Women between the ages of 40 and 60 are affected most often. Or a secondary frozen shoulder can develop after an injury such as a fracture, soft tissue damage, or surgery. Sometimes changes occur in the shoulder joint as a result of osteoarthritis that can also lead to adhesive capsulitis.

Researchers have been studying biopsies of rotator cuff tissue in patients with frozen shoulder who did not get better with conservative (nonoperative) care. They later went on to have surgery to manipulate the shoulder joint. In this procedure, the patient is anesthetized (asleep) while the surgeon moves the joint through its full arc of motion. Any adhesions or fibrous scar tissue is torn in the process, thus freeing up the arm.

Taking a microscopic look at the tissue around the shoulder, they found signs of chronic inflammation. Specific inflammatory cells such as mast cells, T cells, B cells, and macrophages were present. Other studies have shown that vimentin (a cellular protein) is present whenever the anterior shoulder capsule is involved.

Finding specific patterns of pathology at the tissue level may help direct future treatment. Knowing that there are inflammatory cells present may explain why steroid injections seem to have a short-term benefit. Patients get pain relief and improved motion and function. But it’s only good for the first six weeks.

The authors summarize the results of studies of shoulder manipulation with the patient under anesthesia. Two groups of patients were observed. All patients received a home program of stretching exercises. One group had manipulation as well. There was no difference in results between the two groups at the end of one-year. The authors point out that these results suggest manipulation is not needed when the patient is actively engaged in an exercise program.

This type of response may be explained by looking at the natural history of shoulder adhesive capsulitis. There are three phases of frozen shoulder: freezing, frozen, and thawing. Although it can take months to years, most patients experience full recovery (even without treatment).

But this is not to say that treatment isn’t needed. Intervention can shorten the amount of time patients suffer with pain and loss of function. Specific treatment may depend on the stage of the disease (which phase is present) and the patient’s symptoms. Most treatments (steroids, physical therapy, arthrolysis) haven’t been studied enough to know which one works best and at what phase.

Arthrolysis refers to the process of injecting air and/or steroids into the joint with enough volume to distend the joint space. The result is a snapping or breaking of the fibrous adhesions holding the joint and keeping it from moving smoothly. Studies using arthrolysis with and without physical therapy show a distinct advantage when using them both together.

Arthroscopic release can be done. But this is an invasive procedure with its own complications and risks. Damage to the axillary nerve can occur. Positioning the arm in abduction away from the body and neutral rotation can reduce the risk of nerve injury.

Arthroscopic release of the joint capsule with gentle manipulation has been proven reliable in restoring motion. This procedure works well for patients who have not responded to nonsurgical treatment.

The authors recommend treating all patients with frozen shoulder of unknown cause conservatively at first. Nonsteroidal antiinflammatory drugs (NSAIDs) are prescribed. Steroid injections or oral steroid may be used. Patient education should include giving them a choice of home-based or supervised physical therapy. The natural history of frozen shoulder with its three phases is discussed.

Since it is likely to improve on its own, surgery is only offered when patients fail to improve as expected. How much of the joint capsule to release (just the anterior portion, anterior plus posterior capsule release, or global/360-degree release) seems to be based on surgeon preference. More studies are needed to compare these techniques and determine if one has better results (or worse outcomes) than the others.

Many studies fail to study one treatment modality at a time. When two or more are combined, it’s more difficult to tell the true treatment effects of each management tool. In time, studies evaluating each modality alone and in various combinations will help guide treatment for this persistently painful condition.

There’s a common belief that research published today is already outdated before it goes to press. To combat that problem and help keep us up-to-date, frequent, short-term reviews of published research are conducted and summarized in this journal. The topic of this article is disorders of the superior labrum in the shoulder.

The labrum is a ring of dense fibrocartilage around the rim of the acetabulum (shoulder socket). It helps stabilize the head of the humerus (upper arm bone) in the acetabulum. Information on the diagnosis and treatment of superior labral anterior-posterior (SLAP) tears is presented from studies published in the last two years.

A SLAP tear means the labrum is torn away from the acetabulum in two directions: forward (anterior) and back (posterior). The word superior tells us the tear is along the upper rim or top of the acetabulum.

This is a serious injury that doesn’t happen very often. Overhead athletes are at greatest risk. Cocking the arm back to throw puts the shoulder in a position that can cause a SLAP tear. There has also been some speculation that forceful traction or countertraction represents a traumatic cause of SLAP injuries. But studies of cadavers (bodies saved after death for study) don’t support this theory.

There are four basic types of SLAP lesions labeled I through IV. They represent type of tear, location of tear, and severity of tear. For example, with type I there is fraying of the labrum. In Type II the tear extends into the biceps tendon, which attaches to the labrum. Type III is a bucket-handle shaped tear. It does not include the biceps. And type IV is a bucket-handle shaped tear with involvement of the biceps tendon.

The physician uses a wide range of tests and measures to diagnose and classify a SLAP tear. Most physicians are familiar with a group of commonly applied clinical tests such as the O’Brien active compression test, the biceps load test, and the pain provocation test. One other well-known clinical test includes the modified Jobe relocation test. If any of these tests are positive, then further diagnostic measures are needed.

Range-of-motion testing must be done comparing the involved side to the normal (pain free) shoulder. The examiner is specifically looking for a glenohumeral internal rotation deficit (GIRD). Without normal rotational patterns, athletes lose the ability to throw overhand effectively.

These clinical tests don’t usually tell whether the lesion is Grade I, II, III, or IV. Advanced imaging with magnetic resonance arthrography (MRA) is needed to confirm the clinical diagnosis. MRA is considered accurate, sensitive, and specific enough to rely upon.

Scientists using arthroscopy to follow-up and confirm MRA results have been able to refine what SLAP tears look like on MRA. The level and experience of the radiologist evaluating the MRAs is also important in recognizing these lesions.

Likewise, studies have reported positive signs the surgeon can look for when performing an arthroscopic exam. For example, some signs of a type II SLAP lesion include a bare sublabral footprint, peel-back sign, displaceable biceps root, or positive drive through sign. The surgeon is well-acquainted with the meaning of each of these signs.

The authors do mention that studies show the reliability of interobserver reliability for arthroscopic exams is very poor. This means that if 10 physicians looked at the arthroscopic video to evaluate and diagnose the condition, only six of the 10 would agree. That is only slightly more than half, which means 40 per cent disagree. This low level of agreement suggests the need to look at arthroscopic exams very carefully before making a final diagnosis.

Once the diagnosis has been made, then a plan of care is decided upon. Treatment may be nonoperative first. Athletes are shown how to change the way they do things in order to take the pressure off the structures and let them heal. Pain relievers, corticosteroid injections, and antiinflammatory drugs may be used.

A program of physical therapy is prescribed. The therapist’s focus is on reducing the glenohumeral internal rotation deficit (GIRD). The rehab program will also work toward improving the flow of movement and energy throughout the entire kinetic chain. Kinetic chain refers to various body parts connected and moving together (entire upper or lower extremity in connection with the body).

Sometimes surgery is needed to débride (clean up) any frayed pieces, reattach the labrum, and/or repair the torn tendon. There are many different ways to approach the surgical treatment of SLAP injuries. It may be a while before we know which surgery works best for each type of SLAP tear. Outcome studies assessing each type of tear are just becoming part of the published literature.

Studies of SLAP injuries are also seeing other injuries or diagnoses along with the SLAP tear. For example, shoulder instability with shoulder dislocation has been linked with SLAP injuries. Anterior (forward) dislocation leads to an anterior labral tear. When the force of the injury is enough to involve the rotator cuff, then the risk of a SLAP tear increases as well.

There can be cysts along with SLAP lesions. If the cyst is large enough or in just the right spot, nerve compression can occur. Both components are usually repaired to assure a good outcome. But more recent research has brought this into question. It seems that patients get just as good of results whether or not the cyst is removed or aspirated (deflated).

Complications after a SLAP repair are usually diagnosed with a follow-up arthroscopic exam. The surgeon can look inside the joint and see exactly what’s wrong. Sometimes the sutures used to repair the SLAP lesion get torn or rub a hole in the cartilage. Failure of the SLAP lesion to heal is another possible post-operative problem.

The authors conclude that much more study is needed to help improve the treatment of SLAP lesions. Type of injury, location of injury, and treatment of the lesion direct the clinical management of this problem. But more knowledge is needed of patient age, anatomy, and function of the labral mechanism.

In this report, orthopedic surgeons for The San Antonio Orthopaedic Group in San Antonio, Texas review the latest research on subscapularis tendon tears. They provide background on anatomy, etiology (causes), diagnosis, and treatment of this condition. Both conservative (nonoperative) care and surgical treatment are included.

The subscapularis muscle is one of the four muscles and tendons that surround the shoulder called the rotator cuff. Rotator cuff tears (RCTs) usually involve the infraspinatus or supraspinatus tendons. But surgeons are starting to see more subscapularis tears in active seniors.

The subscapularis muscle rotates the shoulder inward (internal rotation). It stabilizes the shoulder and helps prevent anterior (forward) dislocation. Recent studies have shown how the subscapularis works together with the infraspinatus muscle to create smooth arthrokinetics (joint motion).

The first EMG study on dynamic muscle function of the subscapularis has been published. Besides acting as an internal rotator, it appears that the subscapularis also helps abduct the arm (move it away from the body). It functions as a shoulder stabilizer during this movement as well as during internal rotation.

With today’s new technology, scientists have also discovered a concept called the tendon footprint. This refers to the shape of the tendon as it inserts or connects with the bone. Shape, width, and size of the subscapularis tendon have been mapped now.

The subscapularis footprint is shaped like the outline of the state of Nevada. It is trapezoidal with a wider area at the top. Knowing where the tear is located within the footprint helps direct treatment.

Although subscapularis tears can occur alone, they usually develop when other tendons in the rotator cuff are damaged. Injury from trauma and degenerative processes are two of the most common causes of subscapularis tears. Trauma is more likely to result in an isolated subscapularis tear. Younger patients and especially males are subject to this type of subscapularis injury.

Degenerative processes are more common in older adults. For example, stress on the footprint (place where the subscapularis inserts) from failure of other rotator cuff tendons is more likely as we age.

The roller wringer effect has been described in association with age-related degenerative disorders of the subscapularis tendon. This refers to the effect of impingement (pinching), which can cause the undersurface fibers to tear. This condition is called traumatic undersurface fiber failure (TUFF). As the subscapularis passes under the coracoid process, it gets pressed or pinched.

The coracoid process is a small finger-like structure on the upper outer portion of the scapula (shoulder blade). It points forward on a diagonal and works with the acromion (curved bone over the top of the shoulder) to stabilize the shoulder joint. Because of the shape of the coracoid process and the way the subscapularis passes under it, the tendon can get rolled and wrung out like a wet towel. That’s what’s meant by the roller wringer effect.

In order to make an accurate diagnosis, the surgeon must examine the shoulder carefully. Patterns of pain and loss of motion help guide the diagnostic process. New clinical tests are being developed and tested. The old tests (lift off, Napoleon, belly press) are not as accurate as we once thought. In fact, for small or partial thickness subscapularis tears, these tests are very inaccurate.

The belly-off sign is very sensitive for all sizes of subscapularis tears. With the arm internally rotated and the hand resting against the belly, the patient tries to lift the hand away from the stomach while the examiner resists the motion. Inability to move the hand off the abdomen is a sign that the subscapularis is not functioning properly. But the test requires the patient to use the external rotator muscles. If these are torn in a massive rotator cuff, the test can’t be used.

A new test called the bear-hug test may be the answer. In this test, the patient places the hand of the involved shoulder on his or her opposite shoulder. The fingers are straight and pointing back. The forearm and elbow are lifted up (the point of the elbow is facing forward).

The examiner tries to pull the patient’s hand up and off the shoulder. The patient tries to keep the hand on the shoulder. With a normal, strong scapularis, the patient should be able to keep the hand down. With a subscapularis tear, the examiner will be able to easily lift the patient’s hand off the shoulder. Compared with other tests for subscapularis tears, the bear-hug is the most accurate. But more studies are needed to confirm the use of this test with partial- and full-thickness tears.

In the meantime, research efforts have been made to look at preoperative imaging as a diagnostic tool. CT scans and MRIs haven’t been very successful identifying subscapularis tears. Arthroscopic exam still remains the most sensitive and reliable test. It is more invasive, especially for those patients who don’t have a rotator cuff tear. But it is the first-step in the treatment of rotator cuff tears. So, if the patient’s history and clinical exam point in the direction of a subscapularis tear, then arthroscopic exam is advised.

If the diagnosis is confirmed that a subscapularis tear is present, then the decision about the most effective treatment must be made. Conservative (nonoperative) care is possible but only with a few, select patients. Usually these patients either don’t want surgery or are too medically unstable to have surgery of any kind.

Most people with a torn subscapularis tendon need surgery for a good result. The procedure can be done with an open incision or arthroscopically through several portals (small puncture holes).

The surgeon may find the tear is impossible to repair. But usually, the tendon is sutured back in place. The natural footprint is restored as much as possible. With the arthroscopic approach, the surgeon can check for undersurface tears (traumatic undersurface fiber failure or TUFF). Without this arthroscopic exam, many undersurface tears would be missed.

Specific types and the use of arthroscopes and the location of the portals are described and discussed in detail. The authors provide both line drawings and arthroscopic photographs to aid the surgeon in understanding the arthroscopic treatment of this condition. Specific surgical techniques (e.g., bone bed preparation, anchor placement, suture passage, knot tying) are outlined step-by-step.

Surgery is followed by a rehab program with proper positioning of the arm and limited external rotation for the first six weeks. Once the sling is no longer needed, active motion and limited stretching are allowed. A physical therapist guides the patient through the rehab process, advancing to a strengthening and aggressive stretching program at the right time.

With any new sport, injuries are common. Sport climbing is one of the new activities known to result in shoulder injuries from overuse bordering on addiction. Climbers are so dedicated to the sport, they tend to continue the activity even when injured or advised otherwise by their doctor.

Sport climbing refers to any climbing up or down artificial walls and natural rock faces. There are preplaced outcroppings on the walls called anchors. The climber uses them to get a handhold or foothold during the climb. The climber is secured by a rope above. If he or she falls, the rope stops them. You may have seen some of these walls at parks, schools, or in gyms.

This form of exercise is very demanding on the shoulder muscles. Training is important to improve climbing performance and to prevent injuries. In this study, movements of the shoulder muscles called work profiles were compared between climbers and nonclimbers. The goal was to help physical therapists design specific exercise programs for training or rehabilitation of these athletes.

Two groups of young adults were compared. The first group was experienced climbers (men and women) from a mountaineering group. The second (control) group were healthy adults who were not engaged in regular sports activities using the arms.

Individuals in both groups had normal, stable shoulders with no shoulder or arm symptoms or problems. The strength of shoulder flexors and extensors were measured using a Cybex isokinetic testing system. Only one side (the dominant arm) was tested since climbers use both arms equally. A slow testing speed of 60-degrees per second was used to mimic muscle activity during climbing.

Two types of muscle contractions were tested: concentric andeccentric. Concentric refers to muscles shortening (contracting and getting shorter) during motion. Eccentric means the muscle has already concentrically contracted and is shortened. For example, raising the arm forward and up requires the shoulder flexors to contract concentrically. Lowering the arm back down reverses that action by lengthening (getting longer) the shoulder flexor muscles.

The results showed significant differences for shoulder strength and function between climbers and nonclimbers. Workload generated by the shoulder muscles was higher in the climbers (both men and women). The amount of force produced by flexors and extensors was greater for both concentric and eccentric contractions in the climbing group.

Shoulder extensor muscles were especially stronger — at least two and a half times stronger in the climbing group. This was probably because of the climbing techniques needed to pull the body up during a frontal climb. Climbing puts high demand on these muscles, so regular exercise, training, and climbing activities are needed to develop and maintain this skill.

This was the first published study of muscular function in sport climbers. The relative imbalance in shoulder flexors and extensors may contribute to shoulder injuries. But further studies are needed to confirm this finding. It’s possible that having stronger extensor muscles is essential to prevent shoulder injuries. And the role of other shoulder muscles needed for climbing needs to be studied as well.

Rotator cuff tears involving the subscapularis tendon are rare. Usually the supraspinatus and/or infraspinatus tendons are injured instead. The direction of the more common tears is posterior (backwards). But with a subscapularis rupture, damage occurs at the top of the shoulder (superior portion) and moves in the anterior (forward) direction.

In this study, the unique features of anterosuperior subscapularis tears and their response to surgical repair are examined. Trauma to the shoulder is the usual mechanism of injury. A sudden outward rotation of the shoulder with force can tear the subscapularis. The force is often enough to also tear the supraspinatus tendon and the long head of the biceps brachii tendon.

Besides the history of a specific kind of trauma, the physical exam helps the surgeon make an accurate diagnosis. There are several signs present when the subscapularis is torn. These include weak shoulder internal rotation, too much external rotation, a positive lift-off sign, and a positive belly-press sign.

The lift-off test involves placing the affected arm behind the back (a position of shoulder internal rotation). The back of the hand is against the low back area. The patient attempts to lift the hand away from the spine. The examiner provides resistance to this motion and observes for strength while watching the shoulder blade for abnormal motion.

The belly-press test also checks the subscapularis muscle. The examiner places his or her hand on the patient’s abdomen. The patient places his or her hand of the affected arm over the examiner’s hand. The patient presses his or her hand into the belly while at the same time moving the elbow forward. This action requires the subscapularis to rotate the shoulder. An inability to complete the test suggests dysfunction of the subscapularis.

In this study, thirty (30) patients with a torn subscapularis (confirmed by MRI) had surgery to repair the damage. Not everyone with an anterosuperior rotator cuff tear was offered surgery as an option. Patients were selected carefully by the surgeon.

For example, recent injuries (less than three months) were given priority and advised to have surgery. Patients who tore the rotator cuff within the last three to six months were advised to have surgery if they had pain and loss of motion. Patients with older injuries (more than six months) were included if the surgeon could repair the tendon.

The surgical approach and technique used to repair the damage was determined based on the severity and direction of the tear. X-rays and MRIs helped the surgeon plan the procedure but sometimes, the final decision had to be made during the operation.

The authors explained both their rationale and specific surgical methods used for the group. Treatment with open surgical repair of the rotator cuff tear was discussed as well as treatment of any other tendon damage in the shoulder (e.g., biceps tendon disorder).

Patient characteristics were collected and analyzed. There were far more males than females (80 per cent men, 20 per cent women). Left and right arms were affected fairly equally. Only a small portion of the patient population smoked. More than half had some other medical condition. Three-fourths had a biceps tendon disorder (long head of the biceps torn at the same time as the subscapularis).

Everyone was evaluated thoroughly before surgery. Preoperative motion, strength, function, and pain were measured and compared to postoperative values for each area. Insurance status and satisfaction with results were also evaluated.

Results showed that scores on surveys of the various measures were improved in all areas. Motion, strength, and function related to the rotator cuff were restored to near normal. Near normal values for internal rotation strength showed that healing of the subscapularis occurred. All but one patient said they would have the same surgery again if they had to do it all over again. But 30 per cent weren’t happy with their residual (leftover) symptoms.

In general, satisfaction was less when the supraspinatus or infraspinatus tendon was torn along with the subscapularis. The authors say this makes sense because larger tears involving more soft tissue structures don’t recover as well as simple tears. Patients with worker’s compensation were more likely to have a poor result.

Most of the patients in this study had surgery within six months of the injury. The authors think this may account for better results than is reported in other studies where surgery was done later. Scarring and tendon retraction increase with time. When these factors are combined with poor tendon quality, results can be less than optimal.

The final conclusion of this study was that it is possible to restore a traumatically injured anterosuperior rotator cuff tear to near normal. Surgery done early after the injury can restore shoulder function.