Active Arm Elevation Research Articles

Reverse Total Shoulder Arthroplasty Alters Humerothoracic, Scapulothoracic, and Glenohumeral Motion During Weighted Scaption.

Reverse total shoulder arthroplasty (rTSA) typically restores active arm elevation. Prior studies in patients with rTSA during tasks that load the arm had limitations that obscured underlying three-dimensional (3D) kinematic changes and the origins of motion restrictions. Understanding the scapulothoracic and glenohumeral contributions to loaded arm elevation will uncover where functional deficits arise and inform strategies to improve rTSA outcomes. In a cohort of patients who had undergone rTSA and a control cohort, we asked: (1) Is there a difference in maximum humerothoracic elevation when scapular plane elevation (scaption) is performed with and without a handheld weight? (2) Is maximum humerothoracic elevation related to factors like demographics, patient-reported outcome scores, isometric strength, and scapular notching (in the rTSA group only)? (3) Are there differences in underlying 3D scapulothoracic and glenohumeral motion during scaption with and without a handheld weight? Ten participants who underwent rTSA (six males, four females; age 73 ± 8 years) were recruited at follow-up visits if they were more than 1 year postoperative (24 ± 11 months), had a BMI less than 35 kg/m 2 (29 ± 4 kg/m 2 ), had a preoperative CT scan, and could perform pain-free scaption. Data from 10 participants with a nonpathologic shoulder, collected previously (five males, five females; age 58 ± 7 years; BMI 26 ± 3 kg/m 2 ), were a control group with the same high-resolution quantitative metrics available for comparison. Participants in both groups performed scaption with and without a 2.2-kg handheld weight while being imaged with biplane fluoroscopy. Maximum humerothoracic elevation and 3D scapulothoracic and glenohumeral kinematics across their achievable ROM were collected via dynamic imaging. In the same session the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and isometric strength were collected. Data were compared between weighted and unweighted scaption using paired t-tests and linear mixed-effects models. When compared with unweighted scaption, maximum humerothoracic elevation decreased during weighted scaption for patients who underwent rTSA (-25° ± 30°; p = 0.03) but not for the control group (-2° ± 5°; p = 0.35). In the rTSA group, maximum elevation correlated with the ASES score (r = 0.72; p = 0.02), and weighted scaption correlated with BMI (r = 0.72; p = 0.02) and the SST (r = 0.76; p = 0.01). Scapular notching was observed in three patients after rTSA (Grades 1 and 2). Four of 10 patients who underwent rTSA performed weighted scaption to less than 90° humerothoracic elevation using almost exclusively scapulothoracic motion, with little glenohumeral contribution. This manifested as changes in the estimated coefficient representing mean differences in slopes in the humerothoracic plane of elevation (-12° ± 2°; p < 0.001) and true axial rotation (-16° ± 2°; p < 0.001), scapulothoracic upward rotation (7° ± 1°; p < 0.001), and glenohumeral elevation (-12° ± 1°; p < 0.001), plane of elevation (-8° ± 3°; p = 0.002), and true axial rotation (-11° ± 2°; p < 0.001). The control group demonstrated small differences between scaption activities (< |2°|), but a 10° increase in humerothoracic and glenohumeral axial rotation (both p < 0.001). After rTSA surgery, maximum humerothoracic elevation decreased during weighted scaption by up to 88° compared with unweighted scaption, whereas 4 of 10 patients could not achieve more than 90° of elevation. These patients exhibited appreciable changes in nearly all scapulothoracic and glenohumeral degrees of freedom, most notably a near absence of glenohumeral elevation during weighted scaption. Patients with rTSA have unique strategies to elevate their arms, often with decreased glenohumeral motion and resultant compensation in scapulothoracic motion. In contrast, the control group showed few differences when lifting a handheld weight. Functional deficiency in activities that load the shoulder after rTSA surgery can affect patient independence, and they may be prevalent but not captured in clinical studies. Pre- or postoperative rehabilitation to strengthen scapular stabilizers and the deltoid should be evaluated against postoperative shoulder function. Further study is required to determine the etiology of deficient glenohumeral motion after rTSA, and the most effective surgical and/or rehabilitative strategies to restore deficient glenohumeral motion after rTSA.

Is the angular onset of pain during arm elevation associated to functioning in individuals with rotator cuff related shoulder pain?

BackgroundRotator cuff related shoulder pain (RCRSP) is the main diagnosis for shoulder pain. A painful arc during active arm elevation is a common finding in RCRSP. The angular onset of pain during arm elevation may play an important role on functioning of the upper extremities. ObjectiveThis study aimed to: 1) determine and characterize the association between the angular onset of pain during arm elevation and upper-limb self-reported functioning, 2) verify whether demographic and clinical characteristics contribute to this association, and 3) investigate whether these characteristics differ considering distinct ranges of angular onset of pain in individuals with RCRSP. Methods252 individuals with RCRSP were divided in 3 groups based on the angular onset of pain during arm elevation in the sagittal plane: <60°, 60°-120°, and >120°. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was used to assess functioning of the upper limbs. Demographic and clinical characteristics were selected for the multivariable analysis. ResultsIndividuals with an angular onset of pain above 120° of arm elevation presented lower DASH score (lesser disability) than individuals with an angular onset of pain between 60°- 120°. Male sex, age, dominance of the side affected, duration of symptoms, and the angular onset of pain during arm elevation explained 31% of the DASH score variance. ConclusionIndividuals with RCRSP and angular onset of pain above 120° of arm elevation present better functioning than individuals with onset of pain between 60°-120°, and similar functioning as those with pain below 60°. Male sex, lower age, non-dominant side being affected and longer duration of symptoms are also associated to better functioning as assessed by the DASH questionnaire.

Differences in scapular motion and parascapular muscle activities among patients with symptomatic and asymptomatic rotator cuff tears, and healthy individuals.

BackgroundAltered scapular motion is thought to be one of the factors associated with the development of symptomatic rotator cuff tears. However, the differences in kinematics and muscle activities of scapular upward/downward rotation between patients with symptomatic and asymptomatic tears are unclear. The purpose of this study was to compare the differences in kinematics and muscle activities of scapular rotation among patients with symptomatic and asymptomatic tears, and healthy individuals.MethodsTwenty-three patients with rotator cuff tears and 9 healthy individuals (healthy group) participated in this study. Based on a visual analog scale (VAS, 0-100 mm), the patients were divided into symptomatic (13 patients; VAS ≥20 mm) and asymptomatic (10 patients; VAS <20 mm) groups. Scapular upward rotation was measured with a digital inclinometer. Elasticities of the upper trapezius, levator scapulae, and rhomboid major were assessed by using ultrasound real-time tissue elastography to quantify their muscle activities. All measurements were performed at 0°, 60°, 90°, and 120° of active arm elevation in the scapular plane.ResultsScapular upward rotation was significantly less in the symptomatic group (9.4° ± 5.6°) compared with the asymptomatic group (15.7° ± 6.0°; P = .022) at 90° of arm elevation. The activity of the levator scapulae was significantly higher in the symptomatic group compared with the asymptomatic and healthy groups (P = .013 and P = .005, respectively) at 90° of arm elevation. The activity of the upper trapezius was significantly higher in the symptomatic group compared with the healthy group (P = .015) at 120° of arm elevation.ConclusionPatients with symptomatic rotator cuff tears showed less scapular upward rotation and higher activity of the levator scapulae at 90° of arm elevation compared to patients with asymptomatic rotator cuff tears.

Does forward head posture change subacromial space in active or passive arm elevation?

ABSTRACT Objectives: Forward head posture (FHP) is one of the most common musculoskeletal disorders that appears to affect the shoulder joint through the shared muscles between the head and neck area and the shoulder girdle. The present study compared the acromiohumeral distance between individuals with normal head and neck alignment and those with moderate and severe FHP in active and passive arm elevation. Methods: Based on the craniovertebral angle, 60 volunteers were selected and equally distributed among three groups, including group one with normal head and neck alignment, group two with moderate FHP and group three with severe FHP. The space between the humeral head and the acromion was measured in 10°, 45° and 60° of active and passive arm elevation as the acromiohumeral distance. Results: The acromiohumeral distance was only different between the three groups at 45° arm elevation angle, and this difference was significant between groups one and three. In active and passive arm elevation, increased arm elevation angle reduced the subacromial space significantly. Also, in each arm elevation angle, the subacromial space differed significantly between the active and passive arm elevations. Conclusions: The acromiohumeral distance was significantly lower in the severe FHP group than the group with normal head and neck alignment in the 45° active arm elevation angle, which could be due to the changed tension in tissues between active and passive arm elevation and also the maximum muscle activity in the 45° active arm elevation angle.

Subacromial space outlet in female patients with multidirectional instability based on hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder measured by ultrasound

The objective of the study was to compare the acromiohumeral distance (AHD) between patients diagnosed with hypermobility type of the Ehlers-Danlos syndrome (hEDS) or hypermobility spectrum disorder (HSD) and healthy controls by evaluating the relative amount the tendon occupies in the subacromial area. Furthermore, the aim was to evaluate if there was a change in AHD with arm elevation within and between groups. Twenty-nine female patients with hEDS/HSD (aged 34 ± 12.9 years) and 20 healthy controls (aged 33 ± 10.8 years) participated in the study. The supraspinatus tendon (SST) thickness and AHD were measured using ultrasound. The interplay between the SST and the AHD was expressed as the occupation ratio (OcAHD), calculated as the SST thickness as a percentage of AHD. The measures were performed in the resting position and in subsequently 45° and 60° of active arm elevation in the scapular plane. The main finding is that patients with hEDS/HSDhave a larger subacromial space outlet compared with the controls when measured by ultrasound. Furthermore, in both groups, we found an increased OcAHD during active arm elevation compared with the resting position, which indicates that similar mechanisms occur for patients with hEDS/HSDand healthy controls. Patients with hEDS/HSDhave a larger available subacromial space outlet compared with healthy individuals. OcAHD increased during active arm elevation compared with the resting position in both groups. This knowledge is important when designing rehabilitation exercise programs for shoulder instability patients with abnormal glenohumeral biomechanics.

Three-dimensional Scapular Kinematics During Arm Elevation in Massive Rotator Cuff Tear Patients.

Rotator cuff tears can influence shoulder kinematics and severely impair function. However, there have been no studies on three-dimensional (3D) shoulder kinematics in massive rotator cuff tear (MRCT) patients. Hypothesizing that MRCT patients could demonstrate significantly changed scapular kinematics during arm elevation in the scapular plane, we compared 3D scapular kinematics in the scapular plane between MRCT patients and healthy elderly subjects. We assessed 15 shoulders of 11 MRCT patients and 16 shoulders of 16 healthy subjects. With the subjects seated, we used an electromagnetic tracking system to calculate the upward rotation, posterior tilt, and internal rotation of the scapula at 10° increments from 30° to 120° with respect to the thorax. We performed two-way analysis of covariance with the initial position of the scapular motion as the covariate and performed multiple comparisons using the Bonferroni method. MRCT patients exhibited significantly higher scapular upward rotation than did the healthy subjects (P < 0.05). There were no significant differences between groups with regard to posterior tilt and internal rotation. This study indicated that when MRCT patients elevated their arms, they exhibited a significantly higher scapular upward rotation at low- to mid-range elevations compared with that of healthy subjects. This difference may have resulted from a compensatory effect in response to the decreased elevation torque caused by the loss of rotator cuff function. These results may assist rehabilitation strategies to improve active arm elevation in MRCT patients.

Analysis of scapular kinematics during active and passive arm elevation.

[Purpose] Early postoperative passive motion exercise after arthroscopic rotator cuff repair remains controversial. To better understand this issue, this study was aimed at evaluating scapular kinematics and muscle activities during passive arm elevation in healthy subjects. [Subjects and Methods] The dominant shoulders of 27 healthy subjects were examined. Electromagnetic sensors attached to the scapula, thorax, and humerus were used to determine three-dimensional scapular kinematics during active arm elevation with or without external loads and passive arm elevation. Simultaneously, the activities of seven shoulder muscles were recorded with surface and intramuscular fine-wire electrodes. [Results] Compared with active arm elevation, passive elevation between 30° and 100° significantly decreased the scapular upward rotation and increased the glenohumeral elevation angle. However, no significant differences in scapular posterior tilt and external rotation were observed between active and passive arm elevation, and scapular plane kinematics were not affected by muscle activity. [Conclusion] Unlike active motion with or without an external load, passive arm elevation significantly decreased the scapular upward rotation and significantly increased the mid-range glenohumeral elevation. These data, which suggest that passive arm elevation should be avoided during the early postoperative period, may expand the understanding of rehabilitation after arthroscopic rotator cuff repair.

Three-Dimensional Scapular Kinematics in Patients with Reverse Total Shoulder Arthroplasty during Arm Motion.

BackgroundThere have been few reports on altered kinematics of the shoulder after reverse total shoulder arthroplasty (RTSA). We investigated differences in 3-dimensional (3D) scapular motions assessed using an optical tracking system between RTSA treated shoulders and asymptomatic contralateral shoulders during arm motion.MethodsThirteen patients who underwent RTSA were assessed for active arm elevation in 2 distinct elevation planes (sagittal plane flexion and scapular plane abduction). Their mean age was 72 years (range, 69 to 79 years) and the mean follow-up was 24.4 months (range, 13 to 48 months). The dominant side was the right side in all the 13 patients, and it was also the side treated with RTSA. Scapular kinematics was recorded with an optical tracking system. The scapular kinematics and the scapulohumeral rhythm (SHR) of the RTSA shoulders and asymptomatic contralateral shoulders were recorded and analyzed during arm elevation.ResultsThere were no significant differences in internal/external rotation and anterior/posterior tilting of the scapula between shoulders during arm motion (p > 0.05). However, upward rotation of the scapula differed significantly during arm motion (p = 0.035 for sagittal plane flexion; p = 0.046 for scapular plane abduction). There were significant differences in the SHR between the two shoulders (p = 0.016 for sagittal plane flexion; p = 0.021 for scapular plane abduction).ConclusionsThe shoulder kinematics after RTSA showed significant differences from the contralateral asymptomatic shoulders. Increased upward rotation and decreased SHR after RTSA indicate that RTSA shoulders use more scapulothoracic motion and less glenohumeral motion to elevate the arm.

The effects of plane and arc of elevation on electromyography of shoulder musculature in patients with rotator cuff tears

BackgroundArm elevations in different planes are commonly assessed in clinics and are included in rehabilitation protocols for patients with rotator cuff pathology. The aim of this study was to quantify the effect of plane and angle of elevation on shoulder muscles activity in patients with symptomatic rotator cuff tear to be used for rehabilitation purposes. MethodsEight symptomatic patients with rotator cuff tears were assessed by using EMG (11 surface and 2 fine wire electrodes) synchronized with a motion analysis. The subjects completed five elevations in full can position (arm externally rotated and thumb up) in frontal, scapular and sagittal planes. Muscle activity in three elevation arcs of 20° (from 0° to 60°) was presented as the percentage of mean activity. Data were analyzed by mixed linear models (α=0.003), and Tuckey Post-hoc comparisons for significant effects (α=0.05). FindingsThe effect of plane was significant for supraspinatus, middle trapezius, anterior, middle, and posterior deltoid, triceps, and pectoralis major (P<0.001). Supraspinatus was more active during abduction than scaption and flexion (P<0.05), and its activity did not increase significantly after 40° of elevation (P>0.05). Infraspinatus had similar activity pattern in the three planes of elevation (P>0.003) with increasing trend in accordance with the elevation angle. InterpretationIn any rehabilitation protocol, if less activity of supraspinatus is desired, active arm elevation should be directed toward flexion and scaption and postponed abduction to prevent high level of activity in this muscle.

Thoracic Spine Manipulation in Individuals With Subacromial Impingement Syndrome Does Not Immediately Alter Thoracic Spine Kinematics, Thoracic Excursion, or Scapular Kinematics: A Randomized Controlled Trial.

Randomized controlled trial. To determine if thoracic spinal manipulative therapy (SMT) alters thoracic kinematics, thoracic excursion, and scapular kinematics compared to a sham SMT in individuals with subacromial impingement syndrome, and also to compare changes in patient-reported outcomes between treatment groups. Prior studies indicate that thoracic SMT can improve pain and disability in individuals with subacromial impingment syndrome. However, the mechanisms underlying these benefits are not well understood. Participants with shoulder impingement symptoms (n = 52) were randomly assigned to receive a single session of thoracic SMT or sham SMT. Thoracic and scapular kinematics during active arm elevation and overall thoracic excursion were measured before and after the intervention. Patient-reported outcomes measured were pain (numeric pain-rating scale), function (Penn Shoulder Score), and global rating of change. Following the intervention, there were no significant differences in changes between groups for thoracic kinematics or excursion, scapular kinematics, and patient-reported outcomes (P>.05). Both groups showed an increase in scapular internal rotation during arm raising (mean, 0.9°; 95% confidence interval [CI]: 0.3°, 1.6°; P = .003) and lowering (0.8°; 95% CI: 0.0°, 1.5°; P = .041), as well as improved pain reported on the numeric pain-rating scale (1.2 points; 95% CI: 0.3, 1.8; P<.001) and function on the Penn Shoulder Score (9.1 points; 95% CI: 6.5, 11.7; P<.001). Thoracic spine extension and excursion did not change significantly following thoracic SMT. There were small but likely not clinically meaningful changes in scapular internal rotation in both groups. Patient-reported pain and function improved in both groups; however, there were no significant differences in the changes between the SMT and the sham SMT groups. Overall, patient-reported outcomes improved in both groups without meaningful changes to thoracic or scapular motion. Therapy, level 1b-.

Improvement of the shoulder function after large segment resection of the proximal humerus with the use of an inverse tumour prosthesis.

Active shoulder function after segmental tumour resection of the proximal humerus and endoprosthetic reconstruction is regularly compromised, while the overall arm function allows a satisfying use in daily activities. The main functional problem remains the loss of huge parts of the shoulder girdle musculature and its bony attachment. In revision arthroplasty inverse shoulder implants can improve the active range of motion significantly in comparison to anatomical shaped prostheses. The aim of this study was to investigate if these promising experiences are transferable to reconstructions after tumour resection of the proximal humerus by using a modular inverse tumour prosthesis. In this study we observed the functional and oncological results of 18 inverse proximal humerus endoprosthetic replacements (IPHP) with the MUTARS system (Implantcast®) after resection of benign (1x giant cell) and malignant (11x primary bone sarcoma, 5x bone metastasis of carcinoma) bone tumours. Mean age at operation was 42years. The mean postoperative follow-up was 33months (range ten to 120). Resection margins were wide in 13 and marginal in five patients. Mean reconstruction length was 15.1cm (range 6-25cm). Mean operation time was 191minutes. The axillary nerve was mostly preserved in 78% (n = 14). At latest follow-up the patients presented a medium MSTS-score of 24.6/30. The mean active arm abduction in the shoulder joint was 78° and 88° active arm elevation for patients with intact axillary nerve function, but significantly reduced for the four patients with compromised deltoid function. One patient needed a surgical revision due to a deep implant infection. The IPHP offers a significant improvement of active shoulder function in patients in whom the axillary nerve can be preserved in comparison to anatomically-shaped implants. However, for patients without any deltoid function there is no benefit regarding an improved active range of motion using an IPHP.

Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation

Scapular dyskinesis is an abnormal scapular motion or position during active arm elevation. Dyskinesis is theorized to contribute to impingement syndrome by decreasing the subacromial space. A corrective maneuver of the scapular assistance test (SAT) proposes to increase scapular upward rotation and posterior tilt to increase the subacromial space. The purpose of this study is to determine the influence that 1) scapular dyskinesis and 2) passive manual correction with the SAT have on subacromial space and 3-dimensional (3-D) scapular kinematics. Forty asymptomatic participants were classified with either obvious dyskinesis (n= 20) or normal motion (n = 20) using the scapular dyskinesis test. The anterior outlet of the subacromial space was measured via the acromiohumeral distance using ultrasound imaging and 3-D scapular orientation was assessed with electromagnetic motion analysis, with the arm at rest 45° and 90° of active elevation with and without the SAT, respectively. There were no differences in acromiohumeral distance or scapular kinematics with static active arm elevation between groups. The SAT increased scapular upward rotation, posterior tilt, and acromiohumeral distance in both groups. Participants with dyskinesis demonstrated greater scapular mobility in upward rotation with the SAT, but no additional increase in acromiohumeral distance. Scapular dyskinesis identified during active motion did not result in different 3-D scapular orientation or acromiohumeral distance during active arm elevation in static positions; however, the SAT altered scapular kinematics and increased acromiohumeral distance. The SAT may be helpful to identify individuals where subacromial compression is producing symptoms, regardless of dyskinesis.

Three-Dimensional Scapulothoracic Motion During Active and Passive Arm Elevation

Three-Dimensional Scapulothoracic Motion During Active and Passive Arm Elevation

Angular position, range of motion and velocity of arm elevation: A study of consistency of performance

To define the normal range, velocity and consistency of the movement of active arm elevation with humerus in neutral or in external rotation using a simplified kinematic model. Nine normal volunteers and the non-involved side of twenty five patients with unilateral shoulder lesion participated. A 3D optoelectronic tracking system was used to register the movement of raising the arm from the normal upright position to maximal elevation in a repetitive way. Peak humeral position, range of movement, velocity of motion and consistency of cycles were analyzed. Descriptive statistics, correlation between variables and with sex, age and side are presented, including differences between performances of movement done in neutral or external rotation. Data of the six variables were: maximal abduction 142 degrees [137.4-147.0], range of motion 118.1 degrees [112-124], maximal velocity 238 degrees/s [209-265]; mean velocity 113 degrees/s [96-130]; coefficient of variation of maximal angular abduction was 2.2% [1.7-2.7]; coefficient of variation of maximal velocity 8.6% [7.3-9.9]. No significant differences were observed either on side, sex or between the shoulder of normal volunteers or that of the patients with opposite shoulder lesions. Participants older than 45 years old showed only a significant slightly lower average velocity. The study confirms the weak association between dependent (biomechanical) and independent variables. As it is described here, analysis of arm elevation has not been previously studied and shows that has a good consistency in angular position, velocity and repeatability of motion in normal conditions which permits a picture of the overall performance of the shoulder.

The Etiology of Rotator Cuff Disease and Treatment of Partial-Thickness Pathology

The rotator cuff is the most common source of shoulder pain and disability. The majority of rotator cuff injuries are caused by overuse, with the supraspinatus, a small tendon with a poor blood supply, most commonly affected. The major function of the rotator cuff is to stabilize the glenohumeral joint during active arm elevation by opposing the superior vector of the deltoid's force. As long as the ability to actively elevate the arm is maintained, all rotator cuff injuries, including full-thickness tears, are candidates for nonsurgical management, the basis of which is strengthening of the rotator cuff and scapulothoracic stabilizers. Surgery should be considered for those patients who fail to improve after at least 3 months of nonsurgical management. Arthroscopic rotator cuff debridement without acromioplasty has short-term and long-term results equal to, if not superior to, subacromial decompression. Avoidance of iatrogenic injury to the coracoacromial arch, which is a secondary static stabilizer of the humeral head against anterosuperior migration, contributes to a low complication rate.

Three-dimensional scapulothoracic motion during active and passive arm elevation

Scapulothoracic muscle activity is believed to be important for normal scapulothoracic motion. In particular, the trapezius and serratus anterior muscles are believed to play an important role in the production and control of scapulothoracic motion. The aim of this study was to determine the effects of different levels of muscle activity (active versus passive arm elevation) on three-dimensional scapulothoracic motion. Twenty subjects without a history of shoulder pathology participated in this study. Three-dimensional scapulothoracic motion was determined from electromagnetic sensors attached to the scapula, thorax and humerus during active and passive arm elevation. Muscle activity was recorded from surface electrodes over the upper and lower trapezius, serratus anterior, anterior and posterior deltoid, and infraspinatus muscles. Differences in scapulothoracic motion were calculated between active and passive arm elevation conditions. Scapular motion was observed during the trials of passive arm elevation; however, there was more upward rotation of the scapula, external rotation of the scapula, clavicular retraction, and clavicular elevation under the condition of active arm elevation. This was most pronounced for scapular upward rotation through the mid-range (90-120 degrees) of arm elevation. The upper and lower trapezius and serratus anterior muscles have an important role in producing upward rotation of the scapula especially throughout the mid-range of arm elevation. Additionally, it appears that capsuloligamentous and passive muscle tension contribute to scapulothoracic motion during arm elevation. Assessment of the upper and lower trapezius and serratus anterior muscles and upward rotation of the scapula should be part of any shoulder examination.

Kinematic Alterations in the Ipsilateral Shoulder of Patients with Hemiplegia Due to Stroke

To evaluate the assumption that shoulder kinematic patterns of the ipsilateral, nonparetic shoulder in hemiplegia are similar to kinematics recorded in a healthy population. Case control study of a convenience sample of ten patients with hemiplegia due to stroke in the subacute phase compared with a control group of similar age. Three-dimensional positions of the scapula and humerus were measured and expressed in Euler angles as a function of active arm elevation in the frontal and sagittal plane and during passive humeral internal/external rotation at an elevation angle of 90 degrees in the frontal and sagittal plane. Compared with controls, in the ipsilateral shoulder of patients, we found both a statistically significant diminished scapular protraction during elevation in the sagittal plane (35 +/- 5 vs. 51 +/- 8 degrees at 110 degrees of humeral elevation) and humeral external rotation during arm elevation in the frontal plane (51 +/- 7 vs. 69 +/- 14 degrees at 110 degrees of humeral elevation). Maximal passive humeral external rotation was found to be impaired in the frontal (64 +/- 13 vs. 98 +/- 14 degrees) and sagittal planes (65 +/- 11 vs. 94 +/- 12 degrees). In addition, there was significantly diminished anterior spinal tilt during humeral internal rotation (-5 +/- 10 vs. -20 +/- 9 degrees) and diminished posterior spinal tilt during external rotation in the frontal plane (-14 +/- 8 vs. -3 +/- 6 degrees). Maximal thoracohumeral elevation in patients was significantly impaired (126 +/- 12 vs. 138 +/- 8 degrees). Clear kinematic changes in the ipsilateral shoulder in patients with hemiplegia were found, indicating underlying alterations in muscle contraction patterns. The cause remains speculative. These results suggest that the ipsilateral shoulder should not be considered to function normally beforehand.

Treatment protocol for an acute large rotator cuff repair

Objective To describe the treatment protocol following a large repair of the rotator cuff. Design Case report of postoperative programme. Participant Fifty-six-year-old male with rotator cuff tear. Intervention The protocol was delivered in three phases: Phase I, passive range of motion for 6 weeks following surgery; Phase II, active assisted exercise for Weeks 6–8; and Phase III, resisted exercise for Weeks 8–12. Main outcome measures University of California at Los Angeles (UCLA) pain and function scores, active arm elevation and isometric shoulder rotation strength were measured before surgery and 3 and 6 months postoperatively. Results Full activity without pain was reported 6 months following surgery (UCLA score 10), with active elevation and rotation strength comparable to the unaffected shoulder. Conclusion Further work is now required to validate the effectiveness of the treatment protocol.

The rotator cuff opposes superior translation of the humeral head.

To determine the influence of rotator cuff muscle activity on humeral head migration relative to the glenoid during active arm elevation we studied five fresh cadaveric shoulders. The shoulder girdles were mounted in an apparatus that simulated contraction of the deltoid and rotator cuff muscles while maintaining the normal scapulothoracic relationship. The arms were abducted using four different configurations of simulated muscle activity: deltoid alone; deltoid and supraspinatus; deltoid, infraspinatus, teres minor, and subscapularis; and deltoid, supraspinatus, infraspinatus, teres minor, and subscapularis. For each simulated muscle configuration the vertical position of the humeral head in relation to the glenoid was determined at 30 degrees, 60 degrees, 90 degrees, and 120 degrees of abduction using digitized anteroposterior radiographs. Both muscle activity and abduction angle significantly influenced the glenohumeral relationship. With simulated activity of the entire rotator cuff, the geometric center of the humeral head was centered in the glenoid at 30 degrees but had moved 1.5 mm superiorly by 120 degrees. Abduction without the subscapularis, infraspinatus, and teres minor muscles caused significant superiorly directed shifts in humeral head position as did abduction using only the deltoid muscle. These results support the possible use of selective strengthening exercises for the infraspinatus, teres minor, and subscapularis muscles in treatment of the impingement syndrome.

Reliability of goniometric measurements of active arm elevation in the scapular plane obtained in a clinical setting.

Our purpose was to determine the intratester and intertester reliability of measurements of both scapular and glenohumeral rotation during active arm elevation in the scapular plane with a new device, the scapulohumeral goniometer (SHG). Ten physical therapists, with 1 to 29 years of clinical experience, obtained repeated measurements on 45 subjects who were 27 to 82 years old. All subjects were tested in a uniform standing position with the handheld SHG, which was positioned over the subject's scapula and posterior shoulder according to operationally defined landmarks. For both scapular and glenohumeral rotation, 50% of the time the first and second measurements made on a patient by the same physical therapist differed by 3 degrees or more. Ten percent of the time, these measurements differed by 8 degrees or more. Measurements of active range of movement of scapular and glenohumeral rotation made by the same physical therapist during arm elevation in the scapular plane are clinically unacceptable when obtained with the current techniques for positioning the SHG. Clinical decisions based on results of active scapular and humeral motion in the scapular plane as measured on a patient by the same therapist with an SHG should be made with caution, because of the variability associated with this procedure.