Shoulder Pain that isn't Shoulder Pathology – A Shoulder Surgeon’s Guide to Concomitant Cervical Spine and Rotator Cuff Disease

Study Design:Systematic review.Objective:To assess the current literature regarding the relationship between the shoulder and the spine with regard to (1) overlapping pain pathways; (2) differentiating history, exam findings, and diagnostic findings; (3) concomitant pathology and optimal treatments; and (4) cervical spine-based etiology for shoulder problems.Methods:A systematic literature search was performed according to the guidelines set forth by the Cochrane Collaboration. Studies were included if they examined the clinical, anatomical, or physiological overlap between the shoulder and cervical spine. Two reviewers screened and selected full texts for inclusion according to the objectives of the study. Quality of evidence was graded using OCEBM (Oxford Center for Evidence Based Medicine) and MINORS (Methodological Index for Nonrandomized Studies) scores.Results:Out of 477 references screened, 76 articles were included for review and grouped into 4 main sections (overlapping pain pathways, differentiating exam findings, concomitant/masquerading pathology, and cervical spine-based etiology of shoulder pathology). There is evidence to suggest cervical spine pathology may cause shoulder pain and that shoulder pathology may cause neck pain. Specific examination tests used to differentiate shoulder and spine pathology are critical as imaging studies may be misleading. Diagnostic injections can be useful to confirm sources of pain as well as predicting the success of surgery in both the shoulder and the spine. There is limited evidence to suggest alterations in the relationship between the spine and the scapula may predispose to shoulder impingement or rotator cuff tears. Moreover, cervical neurological lesions may predispose patients to developing rotator cuff tears. The decision to proceed with shoulder or spine surgery first should be delineated with careful examination and the use of shoulder and spine diagnostic injections.Conclusion:Shoulder and spine pathology commonly overlap. Knowledge of anatomy, pain referral patterns, shoulder kinematics, and examination techniques are invaluable to the clinician in making an appropriate diagnosis and guiding treatment. In this review, we present an algorithm for the identification and treatment of shoulder and cervical spine pathology.

The pursuit of ‘best practice’, health economic planning, the increasing awareness and expectations of patients, pressure from politicians and the media, and the emergence of league tables for surgeons are some of the reasons why orthopaedic surgeons are encouraged to adopt evidence-based

Introduction: Shoulder pain is a significant cause of decreased functional activity of an individual. The overall prevalence of shoulder pain is 16-26%, which makes it the third most common cause among musculoskeletal complaints. The cause of pain in the shoulder is often difficult to evaluate, and diagnosis is usually ambiguous because physical findings are poorly reproducible. The diagnosis therefore, requires multiple imaging modalities. Therapeutic arthroscopy is “the current gold standard” for diagnosing shoulder pathologies, however the procedure is invasive, needs hospitalisation and anaesthesia. Aim: To correlate the findings of Magnetic Resonance Imaging (MRI) shoulder with the findings of shoulder arthroscopy and subsequently determine sensitivity, specificity and accuracy of MRI in diagnosing shoulder pathologies. Materials and Methods: Forty two patients suffering from chronic shoulder pain for a period of more than six weeks, having symptoms of instability, clinical signs of tear or impingement, or functional limitation of the affected shoulder were included in this study. The patients included were in the age group of 18-80 years. Subsequently, MRI followed by arthroscopy of the shoulder was done and the findings of MRI were compared to that of arthroscopy using kappa statistics. Results: In this study along with rotator cuff tear (26 patients), subacromial bursitis (26 patients), was the other most common shoulder pathology. The sensitivity of MRI in detecting shoulder pathologies varied from poor (0.28) for Superior Labrum Anterior Posterior (SLAP) lesion to very good (0.88) for Bankart’s tear and (0.8) for synovial chondromatosis to excellent for rotator cuff tears (0.92). Although sensitivity of MRI was variable for different shoulder pathologies, specificity was comparatively high in detecting all of the above shoulder pathologies. The accuracy of MRI was highest (0.95) in diagnosing synovial chondromatosis, followed by bankart’s lesion (0.92), and rotator cuff tear (0.88). Conclusion: MRI is a very useful and effective tool in diagnosing various shoulder pathologies with exception of SLAP tears where its sensitivity diminishes significantly.

Shoulder pain can cause significant pain, discomfort and reduce the ability to perform activities of daily living, thus making it the third most common cause of musculoskeletal consultation. The current gold standard diagnostic investigation is arthroscopy. MRI is a proved sensitive and accurate non-invasive tool in investigating shoulder pathology, but false and misleading results are equally reported. The aim of the study is to compare the efficacy of MRI in diagnosing shoulder pathologies in comparison to arthroscopy, considering arthroscopy as the gold standard. Thirty nine consecutive patients, between 18-80 years of age, presenting with chronic shoulder pain or instability of more than 6 weeks, or with clinical signs of impingement or tear were included in the study. MRI of the shoulder joint was done followed by shoulder arthroscopy. The data collected was analysed for the significant correlation between MRI of shoulder and arthroscopic findings by kappa statistics. Out of 39 patients, Rotator cuff (RC) tear was the most common pathology. MRI showed excellent sensitivity in the diagnosis of rotator cuff tears (0.91) and osteochondral defects (OCD), very good sensitivity for Bankart's lesion (0.8) and had poor sensitivity to detect SLAP tear (0.15). MRI was specific for all shoulder pathologies. MRI detected RC tears with kappa score of 0.73, Bankart's tear and OCD's with kappa score of 0.83 and 1.0 respectively and SLAP lesion with kappa score of 0.14. The accuracy of MRI was highest in diagnosing OCD's (1.0), followed by RC tear (0.9), Bankart's tear (0.9) and accuracy was least in diagnosing SLAP lesion (0.7). False negative results were more than false positives. The present study supports that MRI is effective in diagnosing rotator cuff tears, Bankart's tear and ostechondral defects but was not found to be helpful in diagnosing SLAP lesions. MRI and arthroscopy have complimentary roles in the diagnosis of shoulder pathology.

Coracoid Impingement: A Prospective Cohort Study on the Association between Coracohumeral Interval Narrowing and Anterior Shoulder Pathologies (SS-09)

Background:As youth participation in contact and overhead sports has increased in recent decades, so has the occurrence of traumatic and overuse injuries of the shoulder. Rotator cuff injury (RCI) is an infrequent shoulder pathology in pediatric patients and its description in the literature has been scarce leading to management derived largely from adult-based evidence. Greater understanding of RCI characteristics and treatment outcomes in children and adolescents would improve our understanding of this pathology and help to guide clinical decision-making.Purpose:To identify pediatric patients with MRI-confirmed RCI treated at a single center in order to summarize injury characteristics, treatment and outcomes.Methods:A retrospective review of pediatric patients (<18yo) diagnosed with and treated for a RCI between 1/1/2011 and 1/31/2021. Patient demographics, injury mechanism and type, treatment, and outcomes were collected. Descriptive statistics were performed. Bivariate testing was also used to compare operatively and nonoperatively treated cohorts.Results:Fifty-two pediatric patients treated for a rotator cuff avulsion, partial tear, or complete tear were identified. Table 1.1 details injury characteristics, treatment modalities, and patient outcomes overall and each treatment cohort. Mean age was 14.9yo (10-17) and 67% of patients were male. Injuries were most commonly related to participation in the throwing sports (baseball, football, and softball). Operative management was employed in 23% of patients while 77% were managed nonoperatively. Treatment cohorts differed based on tear type with all complete tears being managed operatively (p<0.01). Associated shoulder pathology was common, with the most frequent finding being anterior shoulder instability pathology. One operative patient experienced a retear. Return to play was longer for operatively managed patients (7.1 vs. 4.5 months, p<0.01).Conclusion:The present study expands the limited data available regarding RCIs in pediatric patients. Most injuries are associated sports and typically involve the supraspinatus tendon. RCIs are not restricted to skeletally mature patients and are frequently associated with other shoulder pathology. RCIs were associated with good outcomes and low rates of reinjury in patients managed both non-operative and operatively. RCI should be considered in throwing athletes with shoulder pain, even in skeletally immature patients. The optimal treatment strategy for each tear type remains uncertain, but outcomes appear favorable for patients overall.Table 1.1Rotator Cuff Injury Characteristics, Treatment Modalities, and Patient Outcomes

Introduction: Shoulder joint is a highly mobile joint but is prone for rotator cuff injuries and dislocations. It is necessary to accurately diagnose rotator cuff and labral injuries so that appropriate plan of action for treatment can be taken. Magnetic Resonance Imaging (MRI) can be used to diagnose and describe the extent of rotator cuff tendon and labral injuries and any secondary rotator cuff muscle abnormalities. Aim: To study the demographic profile of patients presenting with shoulder pain and instability, identify the various rotator cuff injuries causing shoulder pain, identify the rotator cuff interval lesions causing microinstability, identify the various labral and bony pathologies in instability, describe the MRI features of the rotator cuff, rotator cuff interval, labral and bony injuries. Materials and Methods: This study was a cross-sectional study of patients with symptoms of either shoulder pain or instability who underwent MRI evaluation of the shoulder in the Department of Radiodiagnosis, Rajarajeswari Medical College and Hospital, Bengaluru, Karnataka, India, from July 2018 to December 2020. The study population consisted of 54 patients with either shoulder pain or instability who underwent MRI of shoulder. All the MRI scans of the shoulder in this study were performed using 1.5 Tesla Siemens Magnetom Avanto (Tim 76x18) MR machine using a flex coil. Results: The study population consisted of 54 patients comprising of 38 males and 16 females. The age of the patients ranged from 20-77 years. Majority of the patients were older than 50 years constituting about 33.33% of the total study population. Rotator cuff injury was the commonest cause of pain. Tendinosis was the commonest type of rotator cuff injury followed by partial-thickness and full-thickness tendon tears. The commonest grade of tendinosis was mild or grade 1. Supraspinatus tendon was the most commonly affected tendon followed by subscapularis and infraspinatus tendons. Teres minor tendon was normal in all the cases. Anterior instability was the commonest type of instability with equal prevalence of soft tissue Bankart, bony Bankart and Perthes lesions. Biceps pulley lesions resulted in long head of biceps tendon instability, microinstability and internal impingement. Conclusion: Rotator cuff injuries are the commonest cause of shoulder pain and are seen more frequently after the fifth decade. Shoulder instability is most commonly seen in young male adults. Tendinosis is the commonest type of rotator cuff injury. Supraspinatus tendon is the most commonly injured tendon. Anterior instability is the commonest type of shoulder instability. Biceps pulley lesions result in long head of biceps tendon instability, microinstability and internal impingement. MRI can diagnose interstitial or intrasubstance tendon tears which are not visualised on arthroscopy. MRI description of tendon and labral tears, tendon retraction and muscle atrophy can guide the orthopaedician during arthroscopy and in treatmentplanning.

While hand paresthesia and numbness are commonly associated with nerve compression, these symptoms also manifest in shoulder conditions not typically linked to direct nerve involvement, prompting questions about their underlying causes. This review aimed to explore the existing literature on hand paresthesia and numbness in patients with common shoulder pathologies. The goal was to identify gaps in our understanding of the prevalence and mechanisms behind these symptoms. To conduct this review, a search strategy was formulated to target key terms related to hand paresthesia, numbness, and various shoulder pathologies. PubMed, Scopus, Embase via OVID, and Cochrane Library were searched, resulting in an initial pool of 33 articles. After screening and removing duplicates, three relevant studies were included for analysis. Our review analyzed three current studies that demonstrated varying rates of preoperative hand paresthesia and numbness among patients with different shoulder pathologies. Specifically, 54% of patients with subacromial impingement syndrome, 35% of patients with rotator cuff tears, and 40% of patients with either Bankart tears or superior labrum anterior and posterior (SLAP) tears reported experiencing hand paresthesia. Hand numbness was reported by 29% of patients with rotator cuff tears, 40% with Bankart tears, and 55% with superior labrum anterior and posterior tears. The prevalence of hand paresthesia and numbness was positively correlated with higher intensity of shoulder pain among all included studies. Hand paresthesia and numbness have been reported by patients with subacromial impingement syndrome, rotator cuff tears, and glenohumeral labral tears. The prevalence of hand paresthesia and numbness across other shoulder pathologies and their pathophysiology remain to be investigated.

Transfer Technique Is Associated With Shoulder Pain and Pathology in People With Spinal Cord Injury: A Cross-Sectional Investigation

BackgroundAcromial morphology has previously been defined as a risk factor for some shoulder pathologies. Yet, study results are inconclusive and not all major shoulder diseases have been sufficiently investigated. Thus, the aim of the present study was to analyze predictive value of three radiological parameters including the critical shoulder angle, acromion index, and lateral acromion angle in relationship to symptomatic patients with either cuff tear arthropathy, glenohumeral osteoarthritis, rotator cuff tear, impingement, and tendinitis calcarea.MethodsA total of 1000 patients’ standardized true-anteroposterior radiographs were retrospectively assessed. Receiver-operating curve analyses and multinomial logistic regression were used to examine the association between shoulder pathologies and acromion morphology. The prediction model was derived from a development cohort and applied to a validation cohort. Prediction model’s performance was statistically evaluated.ResultsThe majority of radiological measurements were significantly different between shoulder pathologies, but the critical shoulder angle was an overall better parameter to predict and distinguish between the different pathologies than the acromion index or lateral acromion angle. Typical critical shoulder angle-age patterns for the different shoulder pathologies could be detected. Patients diagnosed with rotator cuff tears had the highest, whereas patients with osteoarthritis had the lowest critical shoulder angle. The youngest patients were in the tendinitis calcarea and the oldest in the cuff tear arthropathy group.ConclusionsThe present study showed that critical shoulder angle and age, two easily assessable variables, adequately predict different shoulder pathologies in patients with shoulder complaints.

Space Flight Missions Over 6 Months Significantly Increase the Risk of Shoulder Pathology and Rotator Cuff Tears

Rotator cuff fatty infiltration and muscle atrophy do not impact clinical outcomes after reverse total shoulder arthroplasty for glenohumeral osteoarthritis with intact rotator cuff.

INTRODUCTION: Shoulder impingement and rotator cuff tear are commonly seen in shoulder pathology. Pathological changes in the soft tissue around the shoulder can be due to intrinsic degenerative in tendons or extrinsic mechanical compression due to acromion types. Changes in acromion morphology have been postulated, which might be one of the causes of impingement syndrome and rotator cuff tears. But few study results have shown that role of the acromion is doubtful. Our primary objective was to determine acromion types and their prevalence rate with shoulder pathology. MATERIALS AND METHODS: Our study was a prospective study. Eighty-five patients who met the inclusion criteria were included in the study. According to Bigliani et al., acromion types were classified as type 1 acromion that has a flat undersurface, type 2 acromion that has a curved undersurface, and type 3 acromion that has a hooked undersurface on supraspinatous outlet view radiographs. Types of acromion were correlated with shoulder pathology (shoulder impingement and rotator cuff tear). RESULTS: Out of 85 patients with shoulder pathology, 43 patients had impingement shoulder syndrome and 42 patients had rotator cuff tear. Mean age for the impingement shoulder syndrome group was 39.6 years and for the rotator cuff tear group it was 58.6 years. Overall right shoulder is affected more as compared with the left shoulder. Type 2 acromion was seen in 64.7% study population, type 1 was seen in 23.5%, and type 3 was seen in 11.8%. CONCLUSION: In our study, type 2 acromion is more frequently seen in shoulder pathology involving rotator cuff tear and impingement syndrome.

As youth participation in contact and overhead sports has increased in recent decades, so has the occurrence of injuries of the shoulder. Rotator cuff injury (RCI) is an infrequent shoulder pathology in pediatric patients and its description in the literature has been scarce. A greater understanding of RCI characteristics and treatment outcomes in children and adolescents would improve our understanding of this pathology and help to better guide clinical decision-making. To identify pediatric patients with magnetic resonance imaging-confirmed RCI treated at a single center to summarize injury characteristics, treatment, and outcomes. It was hypothesized that injuries would occur predominantly in overhead throwing athletes and would demonstrate good outcomes among both operatively and nonoperatively treated patients. Cross-sectional study. Level 4. A retrospective review of pediatric patients (<18 years old) diagnosed with and treated for an RCI between January 1, 2011 and January 31, 2021. Patient demographics, injury mechanism and type, treatment, and outcomes were collected. Descriptive statistics were performed. Bivariate testing was used to compare operatively and nonoperatively treated cohorts. A total of 52 pediatric patients treated for a rotator cuff avulsion, partial tear, or complete tear were identified. Mean age was 15 years and 67% of patients were male. Injuries were related most commonly to participation in throwing sports. Operative management occurred in 23% of patients, while 77% were managed nonoperatively. Treatment cohorts differed based on tear type, with all complete tears being managed operatively (P < 0.01). Associated shoulder pathology was common, with the most frequent finding being anterior shoulder instability pathology. Return to play was longer for operatively managed patients (7.1 vs 4.5 months; P < 0.01). The present study expands the limited data available regarding RCIs in pediatric patients. Most injuries are associated with sports and involve the supraspinatus tendon. RCIs were associated with good outcomes and low rates of reinjury in patients managed both nonoperative and operatively. RCI should be considered in throwing athletes with shoulder pain, even in skeletally immature patients. This retrospective study fills the hole in the literature by detailing the patterns associated with RCI characteristics and treatment outcomes. In contrast to studies of adult RCIs, our results suggest that outcomes are good regardless of treatment type.

Patients with shoulder and rotator cuff pathology who exhibit greater levels of psychological distress report inferior preoperative self-assessments of pain and function. In several other areas of orthopaedics, higher levels of distress correlate with a higher likelihood of persistent pain and disability after recovery from surgery. To our knowledge, the relationship between psychological distress and outcomes after arthroscopic rotator cuff repair has not been similarly investigated. (1) Are higher levels of preoperative psychological distress associated with differences in outcome scores (visual analog scale [VAS] for pain, Simple Shoulder Test, and American Shoulder and Elbow Surgeons score) 1 year after arthroscopic rotator cuff repair? (2) Are higher levels of preoperative psychological distress associated with less improvement in outcome scores (VAS for pain, Simple Shoulder Test, and American Shoulder and Elbow Surgeons score) 1 year after arthroscopic rotator cuff repair? (3) Does the prevalence of psychological distress in a population with full-thickness rotator cuff tears change when assessed preoperatively and 1 year after arthroscopic rotator cuff repair? Eighty-five patients with full-thickness rotator cuff tears were prospectively enrolled; 70 patients (82%) were assessed at 1-year followup. During the study period, the three participating surgeons performed 269 rotator cuff repairs; in large part, the low overall rate of enrollment was related to two surgeons enrolling only two patients total in the initial 14 months of the study. Psychological distress was quantified using the Distress Risk Assessment Method questionnaire, and patients completed self-assessments including the VAS for pain, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons score preoperatively and 1 year after arthroscopic rotator cuff repair. Fifty of 85 patients (59%) had normal levels of distress, 26 of 85 (31%) had moderate levels of distress, and nine of 85 (11%) had severe levels of distress. Statistical models were used to assess the effect of psychological distress on patient self-assessment of shoulder pain and function at 1 year after surgery. With the numbers available, distressed patients were not different from nondistressed patients in terms of postoperative VAS for pain (1.9 [95% confidence interval {CI}, 1.0-2.8] versus 1.0 [95% CI, 0.5-1.4], p = 0.10), Simple Shoulder Test (9 [95% CI, 8.1-10.4] versus 11 [95% CI, 10.0-11.0], p = 0.06), or American Shoulder and Elbow Surgeons scores (80 [95% CI, 72-88] versus 88 [95% CI, 84-92], p = 0.08) 1 year after arthroscopic rotator cuff repair. With the numbers available, distressed patients also were not different from nondistressed patients in terms of the amount of improvement in scores between preoperative assessment and 1-year followup on the VAS for pain (3 [95% CI, 2.2-4.1] versus 2 [95% CI, 1.4-2.9], p = 0.10), Simple Shoulder Test (5.2 [95% CI, 3.7-6.6] versus 5.0 [95% CI, 4.2-5.8], p = 0.86), or American Shoulder and Elbow Surgeons scale (38 [95% CI, 29-47] versus 30 [95% CI, 25-36], p = 0.16). The prevalence of psychological distress in our patient population was lower at 1 year after surgery 14 of 70 (20%) versus 35 of 85 (41%) preoperatively (odds ratio, 0.36; 95% CI, 0.17-0.74; p = 0.005). Mild to moderate levels of distress did not diminish patient-reported outcomes to a clinically important degree in this small series of patients with rotator cuff tears. This contrasts with reports from other areas of orthopaedic surgery and may be related to a more self-limited course of symptoms in patients with rotator cuff disease or possibly to a beneficial effect of rotator cuff repair on sleep quality or other unrecognized determinants of psychosocial status. Level I, prognostic study.