Internal Rotation Range Research Articles

Immediate effect of MET of shoulder horizontal abductors and active sleeper stretch on glenohumeral internal rotation deficit in Indian lawn tennis players

IntroductionThroughout the throwing motion, the glenohumeral joint (GHJ) achieves extraordinary movement speeds, forces and ranges of motion (ROMs). When the dominant arm is abducted 90°, the shoulder (GHJ) external rotation ROM is usually greater than the non-dominant arm's. Stretching, in any form, effectively increases the joint range of motion. Stretches that increase range of motion, whether active, passive, or muscle energy technique (MET), have been proven to help manage and prevent injuries related with glenohumeral internal rotation deficit (GIRD). The goal of this study was to see which protocol would be the most beneficial in terms of having an immediate effect on this condition, and if either of the stretches would produce a better result, then that could be utilised to treat athletes, the lawn tennis players in this study, to improve their posterior shoulder flexibility. Material and method30 tennis players of 16–30 years of age with GIRD were recruited for the study. The sample was taken from different lawn tennis courts in Delhi. A detailed assessment of GIRD was done. In order of recruitment for the study, each odd subject was given MET of shoulder horizontal abductors first and Active Sleeper Stretch after an interval of 24 h. The order was reversed for every even subject. Range of motion was compared with before and after the protocols readings. ResultThe result of the study says that the active sleeper stretch increases the internal rotation (IR) range of motion in 30 subjects by an average of 4.8o ± 1.95 and MET of shoulder horizontal abductor by an average of 4.73o ± 2.18. ConclusionThere are limitations of both the techniques over each other. Active sleeper stretch cannot be done by impingement syndrome athletes and MET cannot be done alone. Therefore, either of them can be used according to the convenience of the athlete.

Sequential Ultrasound Assessment of Peri-Articular Soft Tissue in Adhesive Capsulitis of the Shoulder: Correlations with Clinical Impairments-Sequential Ultrasound in Adhesive Capsulitis.

Recently, ultrasound measurements of the shoulder such as thickening of the rotator interval (RI) and the axillary recess (AR) are suggested as specific indicators of adhesive capsulitis. Herein, we evaluated the sequential changes in ultrasound parameters and clinical impairments and the correlation between the two in the case of adhesive capsulitis through a prospective observational study of 56 patients with adhesive capsulitis. Clinical assessments and ultrasound parameters, including the thicknesses of the RI and AR, were surveyed at baseline and after 1, 3, and 6 months. In 56 patients with adhesive capsulitis, the thickness of the AR significantly decreased at each follow-up evaluation, but the thickness of the RI showed a significant decrease only between the baseline and 1-month evaluation. In repeated analyses of correlation, the thickness of the AR was strongly correlated with all clinical impairments except the pain at rest and range of internal rotation in the affected shoulder. The thickness of AR was correlated with clinical impairments in patients with adhesive capsulitis during the 6 months follow up and could be useful as a surrogate marker in patients with adhesive capsulitis.

Handgrip Strength Exercises Modulate Shoulder Pain, Function, and Strength of Rotator Cuff Muscles of Patients with Primary Subacromial Impingement Syndrome.

Background Impingement syndrome was shown to be associated with shoulder pain in 44–70% of patients worldwide. It usually occurs due to imbalance and insufficient activation of the rotator cuff (RC) muscles. Aim This study explores the relative effects of handgrip-strengthening exercises on shoulder function, pain, strength, and active range of motion as part of the treatment program for the patients with primary subacromial impingement syndrome. Materials and Methods A total of 58 patients aged 18-50 years with primary subacromial impingement syndrome were randomly enrolled to participate in this single-blind randomized clinical trial. Out of them, only forty patients have eligibly matched the inclusion criteria and randomly assigned to one of two groups to undergo a standardized therapeutic program consisting of two sessions a week for 8 weeks. The control group prescribed ultrasound therapy, ice, and stretching exercises, while the experimental group followed the same program with the addition of handgrip-strengthening exercises (HGSE). Both patients of conventional therapy (control) and handgrip-strengthening exercises (experimental group) were advised to adhere also to stretching and HGSE exercises once a day at home for eight weeks. The outcomes were the shoulder function, pain intensity, muscle strength, and active range of motion of the shoulder joint. Results Patients treated with conventional interventions plus handgrip-strengthening exercises showed the significant improvement over time in shoulder pain and function, strength of rotator cuff muscles, and pain-free range of motion forward flexion, abduction, and external and internal rotation through eight weeks in the experimental group compared to control patient group treated with conventional interventions. In addition, patients of both control and experimental groups showed no significant difference in the adherence to respective home-based stretching and HGSE exercises once a day at home for eight weeks. Conclusions Adding handgrip-strengthening exercises to conventional intervention increases the efficacy of treatment for patients with primary subacromial impingement syndrome in terms of shoulder function, pain, muscle strength, and active range of motion.

Bilateral glenohumeral internal rotation deficit (GIRD) in elite gymnasts

IntroductionThe “Glenohumeral Internal Rotation Deficit (GIRD)” is known as the difference in internal rotation range of motion (IRRM) between the dominant and non-dominant shoulder of overhead athletes as a result of asymmetric loading. As in contrast loading pattern in gymnastics are quite symmetric and structural changes often occur bilaterally, the question arises if GIRD might develop bilaterally in gymnasts as one source of common bilateral shoulder pathologies and to search for underlying structural adaptations.Materials and methodsA group of 35 elite gymnasts (8–24 years) were recruited from a local Olympic Training Centre and compared to a paired cohort of 28 non-overhead athletes. Clinical examinations, digital range of motion (ROM)-measurement, ultrasonographic humeral torsion measurement, and standardized MRI scans of both shoulders were obtained and examined for structural pathologies, cross-sectional areas (CSA) of the rotator cuff muscles and capsular thickness.ResultsROM-measurements showed significant decrease in IRRM in the gymnasts groups by age, with IRRM of 48.6° (SD: 8.4°, CI 95%: 43.0–54.3°) at age group 1 (8–10 years) and IRRM of 10° (SD: 11.4°; CI 95%: 0–22.0°) at age group 4 (18–26 years), that was statistically significant for the entire cohort (p = 0.017) compared to the controls. CSA were not significantly different between the cohorts, while there was a slightly increased humeral retrotorsion in the gymnasts as well as a statistically significant posterior capsular thickening.ConclusionA new bilateral form of GIRD was identified in higher age groups of youth and senior elite gymnasts enrolled in this study. Despite to former definition of GIRD there was no compensatory increase in external rotation range of motion (ERRM) but an association with posterior capsular thickening, while there was no periscapular muscle hypertrophy. Humeral retrotorsion was also slightly increased in the gymnasts group.

Effect of Selected Corrective Exercises on Glenohumeral Rotation range of Motion in Overhead Athletes with Scapular Dyskinesis

In overhead exercises, performing the repetitive and high-intensity throwing movements causes to reduce the internal rotation range of motion (IR ROM) in the dominant shoulder by applying small and continuous pressures on the glenohumeral joint capsule. This factor can cause scapular dyskinesis (SD) and predispose to shoulder injuries. The purpose of this study was to investigate the effect of eight weeks of selected corrective exercises on the shoulder rotation range of motion and SD in overhead athletes. The present study is a cross-sectional study that was conducted on 54 volleyball players with SD. Goniometer and Lateral scapular slide test (LSST) were used to measure the shoulder rotation ROM and SD, respectively. The experimental group participated in eight weeks of selected corrective exercises. Data were analyzed using an independent t-test. In the experimental group, the shoulder IR ROM and SD after exercise showed a significant increase (P= 0.001) and a decrease (P= 0.001), respectively; while in the control group, the changes were not significant. Therefore, the selected corrective exercises can lead to an increase in the shoulder IR ROM and correct the SD in overhead athletes, and it is recommended to consider it as a part of their routine exercises.
 

Glenohumeral internal rotation deficit in volleyball players with and without a history of shoulder pain

ABSTRACT This study aimed to investigate physiological and pathological Glenohumeral Internal Rotation Deficit (GIRD) in volleyball players with and without a history of shoulder pain. Volleyball players with a history of shoulder pain (n = 18) and without a history of shoulder pain (n = 18), who were matched in age, weight, height, BMI, years of experience and frequency of practice were recruited for this cross-sectional study. Shoulder internal and external rotation Range of Motion (ROM) was measured for the dominant and non-dominant shoulders of each participant using a digital inclinometer. Measurements of GIRD, External Rotation Gain (ERG), and Total Range of Motion (TROM) were calculated. There were significantly higher degrees of GIRD in the pain group (15.65⁰) than the no-pain group (9.06⁰) (p=0.004) and significantly higher differences in the TROM in the pain group (16.17⁰) than the no-pain group (10.17⁰) (p=0.007). There was no correlation between the level of pain and the presented ROM adaptations. The study showed that for volleyball players, pathological GIRD should be defined at 10-18⁰ degrees of GIRD that are accompanied by differences in the TROM that exceeds 8⁰.

Histological changes and neural elements in the subacromial bursa on patients with rotator cuff tear: Pilot study.

Objective:This study aimed to investigate the neural elements of the subacromial bursa (SAB) in rotator cuff tears.Materials and methods:Twenty patients with rotator cuff tears were recruited, and their visual analog scale (VAS) score, duration of symptoms, and range of motion (ROM), including flexion, external rotation, and internal rotation were evaluated. Tear size was measured using magnetic resonance imaging (MRI). The SAB specimens obtained during arthroscopic rotator cuff repair were studied using routine hematoxylin and eosin staining and immunohistochemistry (S-100 protein and PGP 9.5 protein). The SAB specimen for the control group was obtained from 2 fresh cadavers and 2 patients with acute humeral shaft fracture. The Mann-Whitney U test was applied to assess the difference between histological findings of the rotator cuff tear group and control group. The correlation between the histological findings and clinical features was evaluated using the Spearman correlation coefficient.Results:The mean duration of symptom was 10.2 ± 6.4 months. The preoperative average VAS score was 2.9 ± 1.2. The degrees of preoperative ROM in forward flexion and external and internal rotations were 143.8 ± 19.5, 49.5 ± 23.1, and –4.3 ± 4.2, respectively. The tear was 2.0 ± 0.9 cm. For histological findings, the number of neural elements per low power field in the rotator cuff tear group was significantly less than the control group in both immunohistochemical stainings (S-100: 0.5 ± 0.7 vs 2.8 ± 0.5, p < .01; PGP 9.5: 0.4 ± 0.7 vs 3.5 ± 0.6, p < .01). During the correlation analysis, the number of neural elements in the PGP 9.5 staining was negatively correlated with the ROM in forward flexion and external rotation.Conclusion:This study revealed that chronic rotator cuff tears may induce degeneration of neural elements in SAB.

Posterior shoulder capsule of the dominant arm is stiffer in baseball players than that in nonthrowing population.

Posterior shoulder capsule tightness is one of the factors for shoulder injuries in overhead athletes. Recent studies have shown the posterior capsule of the dominant arm to be stiffer than that of the nondominant arm in baseball players. However, whether posterior capsule tightness in the dominant arm is exclusive to overhead athletes remains unknown. This study aimed to investigate whether the posterior shoulder capsule of the dominant arm in baseball players is stiffer than that in nonthrowing population. Fifteen male collegiate asymptomatic baseball players (baseball-player group) and fifteen male college students who did not partake in overhead sports (nonthrowing group) participated in this study. We measured the shear moduli of the middle and inferior posterior capsules, superior infraspinatus, inferior infraspinatus, teres minor, and posterior deltoid in the dominant arm by ultrasound shear wave elastography. We compared shear moduli between the two groups using an independent samples t-test and Mann-Whitney test. In addition, we investigated the correlation between the range of glenohumeral internal rotation and each shear modulus in each group using the Pearson correlation coefficient. The shear moduli in the baseball-player group were significantly higher than those in the nonthrowing group in both the middle posterior capsule (baseball-player group: 36.1±5.6kPa vs. nonthrowing group: 29.0±8.6kPa; P=.018) and inferior posterior capsule (37.1±9.6kPa vs. 27.9±6.8kPa; P=.002). However, no difference in the shear moduli of individual muscle groups was identified. The glenohumeral internal rotation range exhibited a statistically significant negative correlation with the shear modulus of the inferior posterior capsule in the baseball-player group (Pearson correlation coefficient=-0.586, P=.022). Our findings suggest that the posterior shoulder capsule of the dominant arm in baseball players is stiffer than that in nonthrowing population.

Poster 128: Association Between Postoperative Graft Integrity and Clinical Outcomes After Superior Capsule Reconstruction: A Multicenter Study

Objectives:Superior capsule reconstruction (SCR) was developed as a joint-preserving surgical option for patients with irreparable rotator cuff tears (RCTs). Previous studies have postulated that graft thickness and graft healing may be important factors for optimizing the clinical outcomes of SCR. However, the correlation between postoperative graft integrity and clinical outcomes after SCR remains unclear. The objective of this study was to assess the correlation between postoperative graft integrity and clinical outcomes after SCR in patients with irreparable RCTs.Methods:This retrospective multicenter study enrolled 188 patients (86 women and 102 men; mean age, 69.2 years; range, 49–87 years) who underwent arthroscopic SCR using fascia lata autografts for irreparable RCTs from five different centers. Postoperative graft integrity was evaluated using magnetic resonance imaging and was classified into five categories: type I, sufficient graft thickness with homogeneously low intensity; type II, sufficient graft thickness with partial high intensity; type III, insufficient graft thickness (4 mm or less) without discontinuity; type IV, presence of a minor discontinuity in less than four slices on both oblique coronal and sagittal images, suggesting a small graft tear; type V, presence of a major discontinuity in four or more slices on both oblique coronal and sagittal images, suggesting a large graft tear. We compared the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, active shoulder range of motion (ROM), muscle strength (assessed with manual muscle test), and acromiohumeral distance (AHD) among the five groups based on postoperative graft integrity. For the statistical analyses, Kruskal-Wallis test (nonparametric one-way analysis of variance) followed by pairwise group comparisons using the Dwass-Steel-Critchlow-Fligner procedure was used to compare the values among the five groups based on the postoperative graft integrity assessment. Paired t-test or Wilcoxon signed-rank test was used to compare the preoperative and postoperative clinical outcome measures and AHD. Statistical significance was defined as P <0.05.Results:VAS and ASES score significantly improved after SCR in all graft types (all P<.05) (Table 1). However, shoulders with type V grafts had significantly inferior postoperative VAS and ASES score compared to those with type I and II grafts (all P<.05). Shoulders with intact grafts (types I, II, and III) showed significant improvements in shoulder ROM (all P<.05) (Table 2) and muscle strength after SCR (all P<.05) (Table 3). In contrast, shoulders with graft tears (types IV and V) showed no significant improvement in the range of external and internal rotation and shoulder muscle strength in any direction. Postoperative AHD was significantly increased only in shoulders with sufficient graft thickness (types I and II) (both P<.0001) (Table 4).Conclusions:Arthroscopic SCR provided pain relief even in patients with graft tears. However, patients with large graft tears had significantly inferior postoperative clinical scores compared to those with intact graft of sufficient thickness. Shoulder ROM and muscle strength were increased after SCR in shoulders with intact grafts but not in those with large graft tears. Postoperative AHD was significantly increased only in shoulders with intact graft of sufficient thickness. These results suggest that postoperative graft integrity affect clinical outcomes after SCR. An intact graft of sufficient thickness restored glenohumeral stability and substantially improved clinical outcomes.Table 1.Change in Visual Analog Scale and American Shoulder and Elbow Surgeons score after Superior Capsule ReconstructionTable 2.Change in Active Shoulder Ranges of Motion from Preoperative to Postoperative EvaluationTable 3.Change in Shoulder Muscle Strength after Superior Capsule ReconstructionTable 4.Change in Acromiohumeral distance after Superior Capsule Reconstruction

Poster 142: Identifying the Bony and Soft Tissue Mechanisms Responsible for Glenohumeral Internal Rotation Range of Motion

Objectives:Shoulder and elbow injuries account for about one-fourth of the total injuries in professional baseball players. The loss of shoulder internal rotation range of motion (IR ROM) has been identified as a significant risk factor for upper extremity injuries in pitchers across all ages. Several anatomic structures have been independently associated with IR ROM. First, greater amounts of humeral retroversion (HR) have been related to decreased IR ROM. Second, increased posterior capsule thickness (PCT) has also been related to decreased IR ROM. Lastly, adaptations to the teres minor muscle pennation angle (PA) has been related to losses in IR ROM and the PA of both the infraspinatus and teres minor have been related to the acute decrease in IR ROM following pitching. However, these three anatomic structures have not been collectively measured in baseball pitchers to determine the underlying mechanisms responsible for IR ROM. Therefore, this study will determine the contributions of HR, PCT, and posterior rotator cuff PA on IR ROM in healthy professional baseball pitchers. We hypothesized that HR, PCT, and posterior rotator cuff PA would have a significant contribution to IR ROM.Methods:51 healthy professional pitchers were recruited for this cross-sectional study at the beginning of the 2021 Major League Baseball spring training. Participants received a bilateral IR ROM assessment while laying supine with the shoulder at 90 degrees of abduction and the scapula stabilized. Ultrasound imaging was also performed bilaterally to assess HR, PCT, infraspinatus (superficial + deep) PA, and teres minor (superficial + deep) PA. All ultrasound imaging was performed utilizing a previously published standardized technique. A stepwise regression was performed which included both arms to determine the mechanisms of IR ROM.Results:The first variable to enter into the stepwise regression model was HR which had a moderate relationship with IR ROM (regression coefficient of -0.502). PCT also entered the model, as measuring both HR and PCT improved the relationship with IR ROM from moderate to strong (regression coefficient of -0.657). Infraspinatus and teres minor PA did not enter the predictive model of IR ROM.Conclusions:HR and PCT were found to be the primary anatomic mechanisms responsible for glenohumeral IR ROM. Surprisingly, the posterior rotator cuff PA was not found to be a significant predictor of IR ROM. The posterior rotator cuff may instead contribute more to the acute decrease in IR ROM following pitching, which has recently been reported. As deficits in IR ROM can have harmful effects in baseball pitchers, understanding which anatomic structures are most responsible for IR ROM is important for injury prevention and treatment.Figure 1.Ultrasound image of the infraspinatus, with yellow arrows indicated the superficial infraspinatus pennation angle and green arrows representing the deep infraspinatus pennation angle.CT=central tendon, SN=suprascapular notch.Table 1.Standardized regression coefficients and regression strengths of included and excluded variables in the internal rotation range of motion model.

Paper 09: Differences in Glenohumeral Range of Motion and Humeral Torsion Between Right-Handed and Left-Handed Major League Baseball Pitchers.

Objectives:Substantial differences in throwing metrics, like velocity, spin rate and pitcher break, have been observed between left and right-handed pitchers. Elite pitchers have demonstrated significant changes in glenohumeral range of motion and humeral torsion compared to the normal population. Differences in these anatomical parameters between left and right-handed pitchers may explain these performance trends. Furthermore, changes in shoulder range of motion measurements have been associated with different injury risks and challenges in assessing rehabilitation progress. This study seeks to determine if differences in glenohumeral range of motion and humeral torsion exist between left-handed and right-handed pitchers.Methods:217 MLB pitchers from a single organization were evaluated over a 7-year period from 2013-2020. Range of motion was evaluated by three trained examiners using a Standard Goniometer. Ultrasound scanning was used to determine neutral position of the shoulder and the degree of humeral torsion was measured with a goniometer. The mean and standard deviation were assessed for normality using Shapiro Wilk. Differences between right and left-handed pitchers were assessed using one-way ANOVA. Arm effects were assessed using paired samples t-tests.Results:Right-handed pitchers showed, on average, 13.9 degrees more shoulder external rotation range in their dominant arm compared with their non-dominant arm, whereas left-handers averaged only 2.2 degrees. RHPs showed greater asymmetries in shoulder internal rotation range (13.9 vs 4.8 degrees) and humeral torsion (-23.1 vs -2.2 degrees). Left-handed pitchers showing significantly greater range of non-dominant shoulder flexion (165.8 vs 160.7 degrees) leading to greater flexion deficits in the dominant arm compared to their right-handed counterparts, (7.5 vs 0.0 degrees).Conclusions:Right-handed pitchers demonstrate significantly greater measures of external rotation, humeral retrotorsion, and shoulder flexion compared to left-handed counterparts. The correlation between humeral retrotorsion and increased external rotation indicate that osseus adaptations are a major contributor to range of motion differences associated with handedness. Additionally, these findings may explain observed differences in several throwing metrics between right and left-handed pitchers. Furthermore, knowledge of these differences can inform rehabilitations programs and shoulder maintenance regimens.Table 1.Range of Motion Variables for Right Handed (RHP) and Left Handed (LHP) Professional Baseball Pitchers.*Table 2.Average Velocity in Miles per Hour by Pitch Type and Pitcher Handedness, 2017-2020.a Figure 1.Scatter chart showing the correlation between dominant-arm retrotorsion and external rotation gain in the throwing arm of all pitcher’s studied. As retrotorsion increased, the degree of external rotation also increased. Right-handed pitchers were more likely to have higher degrees of both retrotorsion and external rotation gain. Negative values indicate retrotorsion.Figure 2.Box and whisker plot showing the difference in dominant-arm retrotorsion in the dominant throwing arm in left and right-handed pitchers. Dominant-arm| retrotorsion is the difference in torsion between the dominant throwing and non-throwing arm. Right-handed pitchers demonstrated significantly more retrotorsion (negative torsion) in the dominant throwing arm compared to left-handed pitchers.

Effects of A Progressive Rehabilitation Program on Shoulder Internal Rotation Range of Motion, Acromiohumeral Distance, And Pain in An Adolescent Female Swimmer with Subacromial Pain (Impingement) Syndrome

Shoulder injuries are common in competitive youth swimmers because of sport-specific changes in upper extremity physical characteristics and acromio-humeral distance (AHD). These physical alterations could cause abnormal scapular kinematics and positioning. Subacromial pain syndrome (SPS), scapular dyskinesis, and SLAP lesions require a multiphase approach. A 14-years-old female athlete who has been swimming for 7 years had SPS symptoms for 14 months. She also had scapular dyskinesis and suspected SLAP lesion. She received 15 treatment sessions. We conducted a progressive and comprehensive rehabilitation program consisting of electrotherapy, thermal agent, mobilization techniques, posterior shoulder stretching exercises, upper and lower extremity strengthening, proprioception, scapular stabilization, and core stabilization exercises, rhythmic stabilization exercises, plyometric exercises, and the advanced thrower’s 10 program. Internal rotation range of motion (IRROM) with bubble inclinometer, pain with Visual Analog Scale, and AHD with ultrasonographic imaging were assessed before treatment and at the end of the 9th and 15th treatment sessions. Before treatment, IRROM was 52°, AHD was 10.67 mm, and pain intensity at rest and during swimming was 0 and 3.1 cm, respectively. After 9 treatment sessions, IRROM was 55.6°, AHD was 11.62 mm, pain intensity at rest and during swimming was 3.7 cm and 5.1 cm, respectively. At the end of the treatment, IRROM was 58.33°, AHD was 12.02 mm, pain intensity at rest and during swimming was 0 cm. A progressive and challenging rehabilitation program may positively change the scapular and glenohumeral kinematic patterns leading to an increase in AHD and IRROM, therefore a decrease in pain.

Arthroscopic Repair of Isolated Subscapularis Tears Show Clinical and Structural Outcome Better for Small Tears Than Larger Tears

PurposeTo retrospectively investigate the mid-term outcomes after arthroscopic repair of isolated subscapularis tears with a relatively large number of patients and to compare them by tear size.MethodsMedical records were reviewed for patients who underwent arthroscopic rotator cuff repair between 2010 and 2017 at our institute. The inclusion criterion was isolated subscapularis tears that underwent arthroscopic rotator cuff repair. The exclusion criteria were (1) previous rotator cuff surgery, (2) lack of imaging studies or clinical evaluation data, (3) neuromuscular diseases, and (4) <2-year follow-up. Range of motion, American Shoulder and Elbow Society score, and bear-hug or belly-press test were assessed pre- and postoperatively. Repair integrity was evaluated with magnetic resonance imaging at postoperative1 year. The clinical and imaging study outcomes were compared between smaller (Lafosse types 1-3) and larger (types 4 and 5) tears.ResultsThe subjects included 38 males and 8 females with a mean age of 59 years (range, 25-77 years). The mean follow-up was 36 months (range, 24-96 months). There were 13 type 1, 10 type 2, 12 type 3, 6 type 4, and 5 type 5 shoulders. Postoperative American Shoulder and Elbow Society scores were significantly better in smaller tears than larger tears: 93 ± 8 and 75 ± 14, respectively (P = .003). Smaller tears showed better postoperative internal rotation than larger tears (P = .004). Significant decrease of positive bear-hug or belly-press test was observed in smaller tears (preoperative, 25; postoperative, 11; P < .001), but there was no significant improvement in larger tears (preoperative, 11; postoperative, 9). The retear rate was significantly greater in larger tears (64%) than smaller tears (6%, P < .001).ConclusionsThe clinical and structural outcomes after arthroscopic repair of isolated subscapularis tears were better in smaller tears than larger tears with a mid-term follow-up. Larger tears showed high retear rates with poorer improvement in active range of internal rotation and subscapularis strength.Level of EvidenceLevel III, retrospective, comparative study.

Age related progression of clinical measures and gait in ambulant children and youth with bilateral cerebral palsy without a history of surgical intervention

BackgroundAge related progression needs to be considered when assessing current status and treatment outcomes in cerebral palsy (CP). Research questionWhat is the association between age, gait kinematics and clinical measures in children with bilateral CP? MethodA retrospective database review was conducted. Subjects with bilateral CP with baseline and follow-up 3D gait analyses, but no history of intervening surgery were identified. Clinical and summary kinematic measures were examined for age related change using repeat measures correlation. Interactions with GMFCS classification and whether surgery was recommended were examined using robust linear regression. Timeseries kinematic data for baseline and most recent follow-up analyses were analysed using statistical parametric mapping. Results180 subjects were included. 75% of participants were classified as GMFCS I or II at baseline. Mean time to follow-up was 4.89 (2.8) years (range 1–15.9 years) with a mean age of 6.4 (2.4) at baseline and 11.3 (3.4) at final follow-up. 15.5% of subjects demonstrated an improvement in GMFCS classification while GDI remained stable. Age related progression was noted across many clinical measures with moderate correlations (r ≥ 0.5) noted for reduced popliteal angle, long lever hip abduction and internal hip rotation range. In gait, there was reduced hip extension in late stance (p < 0.001), increased knee flexion in mid-stance (p < 0.001), reduced peak knee flexion in swing (p < 0.001) and increased ankle dorsiflexion in stance (p < 0.001). In the coronal plane, there was reduced hip abduction in swing (p < 0.001). In the transverse plane, increased external rotation of the knee (p < 0.001) and reduced external ankle rotation were noted in early stance and through swing (p < 0.001). There were no changes in foot progression or hip rotation. SignificanceIndividuals with CP show age related progression of clinical and kinematic variables. Treatment can only be deemed successful if outcomes exceed or match these age-related changes.

Chronic Effects of Pitching on Muscle Thickness and Strength of the Scapular Stabilizers in Professional Baseball Players.

The posterior scapular muscles eccentrically contract to disperse the high forces observed in the deceleration phase of pitching. Muscular adaptations often occur following chronic eccentric loading, however, no study has evaluated the adaptations of the posterior scapular muscles with regard to throwing and their relationship with humeral retroversion (HR) in professional pitchers. Significant chronic adaptations in muscle thickness (MT) and strength of the trapezius and rhomboids would be observed in healthy professional baseball pitchers, and there would be a significant relationship between humeral adaptations (ie, HR) and posterior scapular muscle adaptations (ie, strength and MT). Cross-sectional; Level 3. A total of 28 healthy male professional baseball pitchers (age, 22 ± 2 years; mass, 95 ± 17 kg; height, 190 ± 7 cm) were included in the study. Bilateral isometric muscle strength of the upper trapezius (UT), middle trapezius, lower trapezius (LT), and rhomboids was measured during a maximum voluntary isometric contraction. Diagnostic ultrasound images of the UT, middle trapezius, LT, rhomboid major, and rhomboid minor muscles were collected bilaterally to measure MT. HR was also quantified bilaterally with ultrasound. Paired sample t tests were used to compare dominant and nondominant strength and MT. Pearson correlation coefficients were used to assess the relationship between HR, isometric strength, and MT. A significantly increased MT of the LT was found on the dominant arm compared with the nondominant arm (5.4 ± 1.1 mm vs 4.4 ± 1.5 mm; P = 0.00). The Pearson correlation coefficient demonstrated a significant weak negative relationship between HR and rhomboid major MT (P = 0.03; R = -0.36), and a significant weak negative correlation between HR and middle trapezius isometric strength (P = 0.03; R = -0.37). LT thickness was greater in the throwing arm compared with the nonthrowing arm of pitchers, suggesting a positive adaptation of the LT. Interestingly, there was a weak negative relationship between HR and both rhomboid major MT and middle trapezius isometric strength. This negative relationship suggests that since increased HR leads to decreased internal rotation range of motion during deceleration, the scapula may be forced into anterior tilt and protraction, which can place excessive eccentric load on the rhomboid major and middle trapezius.

Exergames to Improve Rehabilitation for Shoulder Injury: Systematic Review and GRADE Evidence Synthesis.

The use of exergames has become an increasingly frequent intervention in rehabilitation, referred to as a fun and motivating activity that involves patients. This systematic review aimed to evaluate the effectiveness of exergames in the rehabilitation of the shoulder joint compared to other types of care. We performed a systematic review and GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) evidence synthesis. The search was conducted using the following databases: MEDLINE, CINAHL, SPORTDiscus, SCOPUS, SciELO, Psychology and Behavioral Sciences Collection, Cochrane Central Register of Controlled Trials, and PEDRo. Databases were searched from the first record until July 2021. Randomized controlled trials using exergames as an intervention were included. The search resulted in 1,048 records. A total of 10 articles published between 2013 and 2020 met inclusion criteria and were reviewed for this study. A positive impact was observed in using exergames to increase shoulders' range of motion, namely, extension, flexion, abduction, internal and external rotation, and functionality postinjury. The results of this review provide evidence of the benefits of exergames in shoulder joint rehabilitation. However, more robust clinical trials need to be developed that assess the effectiveness of using exergames as a complement to traditional rehabilitation and assess participants' degree of satisfaction, motivation, and adherence.

Updates on Management of Avascular Necrosis Using Hip Arthroscopy for Core Decompression.

Osteonecrosis of the femoral head (ONFH) is caused when circulation within the femoral head is disrupted. Etiology of this disease is characterized by either traumatic events or atraumatic risk factors, such as chronic alcohol consumption or glucocorticoid use. ONFH commonly presents as pain in the groin, gluteus muscles, and/or knee with reductions in internal rotation range of motion of the hip. ONFH pathology can be confirmed with radiographic or advanced imaging and characterized by stage, size and location of the lesion. Treatment for ONFH consists of conservative and therapeutic methods as well as surgical intervention. Historically, ONFH has been treated using total hip arthroplasty (THA), but with increasing incidence in a younger, active population, measures to preserve the native hip joint have been explored. Recent advancements in hip arthroscopy and arthroscopy-assisted core decompression have led to improved outcomes, reduced pain and higher hip survival rate for early onset ONFH compared with more invasive approaches such as THA. Biologic treatments combined with arthroscopic core decompression have also shown improved outcomes and quality of life in few reports, suggesting a potential role for biologic adjuncts. The current study provides a comprehensive review and update on the literature surrounding arthroscopy-assisted core decompression for patients with ONFH.

Interaction of hip and foot factors associated with anterior knee pain in mountain bikers

ObjectiveTo investigate the association of interactions among trunk, hip, and foot/ankle musculoskeletal factors with the presence of anterior knee pain (AKP) in mountain bikers. DesignCross-sectional study. SettingPrivate clinical setting. ParticipantsFifty professional and amateur cyclists, with and without AKP, were included. Main outcome measuresBridge test with unilateral knee extension, hip stability isometric test (HipSIT), passive hip internal rotation (IR) range of motion (ROM), shank-forefoot alignment (SFA), and ankle dorsiflexion ROM were analyzed by classification and regression tree (CART) to identify interactions with AKP presence. A receiver-operating characteristic (ROC) curve verified accuracy of the model. To investigate strength of associations, prevalence ratios were calculated for each terminal node of the CART model. ResultsInteractions among passive hip IR ROM, HipSIT, ankle dorsiflexion ROM and SFA identified mountain bikers with and without AKP. The model achieved 76.9% sensitivity and 87.5% specificity. The area under the ROC curve was 0.86 (95% confidence interval: 0.75–0.97; standard error 0.05; p < 0.0001). ConclusionPresence of AKP in mountain bike cyclists was associated with interactions among passive hip IR ROM, HipSIT and ankle dorsiflexion ROM captured by CART, indicating that the contribution of one factor depends on the presence of other factors.

Relationships Among Shoulder Rotational Strength, Range of Motion, Pitching Kinetics, and Pitch Velocity in Collegiate Baseball Pitchers.

Cross, JA, Higgins, AW, Dziuk, CC, Harris, GF, and Raasch, WG. Relationships among shoulder rotational strength, range of motion, pitching kinetics, and pitch velocity in collegiate baseball pitchers. J Strength Cond Res 37(1): 129-135, 2023-Throwing shoulder injuries are the most common type of injury experienced by baseball pitchers. Weakness in the shoulder musculature and insufficient throwing arm range of motion are both risk factors for developing a shoulder injury. The goal of this study was to determine correlations among shoulder rotational strength, range of motion, pitching kinetics, and pitch velocity in collegiate pitchers. Thirteen uninjured male college pitchers were evaluated. Clinical measures included shoulder internal and external rotation range of motion, peak isokinetic internal and external rotator strength, and peak isometric internal and external rotator strength. Three-dimensional biomechanics were assessed as subjects threw from an indoor pitching mound to a strike zone net at regulation distance. Pearson's correlations were used to assess the associations among the clinical measures and throwing metrics. Five significant correlations were found between peak shoulder compressive force and strength, and 4 significant correlations were found between pitching velocity and strength ( p < 0.05). No significant correlations were found between range of motion and pitching kinetics or velocity. Our results suggest that as shoulder rotational strength increases, the peak shoulder compressive force and pitch velocity both increase. Knowledge of relationships between strength metrics and pitching biomechanics may allow for improved strength training routines with the goal of increasing velocity without increasing injury risk.

Acute Effect of Pitching on Range of Motion, Strength, and Muscle Architecture

Background: Acute adaptations in clinical measures of range of motion and strength have been found after baseball pitching; however, there is a lack of research concerning the physiological mechanism responsible for these changes. Adaptations in muscle architecture of the infraspinatus and teres minor may serve as the structural changes responsible for these clinical measure changes. Purpose: To longitudinally assess the acute changes in range of motion, strength, and muscle architecture of the infraspinatus and teres minor muscles in baseball pitchers after a simulated baseball game. Additionally, we examined the relationship between muscle architecture and changes in clinical measures of range of motion and strength. Study Design: Controlled laboratory study. Methods: Ten healthy nonvarsity collegiate club baseball pitchers (mean ± SD; age, 20.1 ± 1.10 years) were examined pre-pitching, immediately after pitching, and each subsequent day for 5 days after pitching in a simulated baseball game. A digital inclinometer and handheld dynamometer were used to assess range of motion and strength, respectively. Diagnostic ultrasound was used to assess pennation angle and muscle thickness of the infraspinatus and teres minor at rest and at maximal contraction. Results: Internal rotation range of motion significantly decreased immediately and did not return to baseline until 4 days after pitching (P≤ .05). External rotation strength also immediately decreased and returned on the third day after pitching (P≤ .05). Moreover, the resting pennation angle of the superficial and deep portions of the infraspinatus increased immediately after pitching, with the superficial portion returning to baseline on day 4 and the deep portion returning on day 5 (P≤ .05). Furthermore, the pennation angle changes of the infraspinatus and thickness of the teres minor were predictive of the loss of internal rotation range of motion after pitching (R2 = 0.419; P≤ .05). Conclusion: This study found diminished internal rotation range of motion and external rotation strength after pitching, with alterations in muscle architecture of the infraspinatus. The pennation angle increase in the infraspinatus at rest is indicative of increased tension in the muscle, which was found to be the underlying mechanism for the clinical loss of internal rotation range of motion. This was demonstrated by the inverse relationship between internal rotation range of motion and the pennation angle of the superficial and deep fibers of the infraspinatus. Clinical Relevance: Clinicians should consider recovery time after pitching to prevent chronic losses of shoulder range of motion and strength. Identification of the underlying mechanisms of range of motion loss after pitching allows clinicians to optimize recovery strategies in baseball pitchers.