Rotator Cuff Strength Research Articles

Profiling Shoulder Strength in Competitive Surfers.

The shoulder region has the highest incidence of acute injuries in the sport of surfing. Little is known about the strength profile at the shoulder in a surfing cohort. The primary aim of this study was to establish the reliability of a rotator cuff strength testing procedure for surfers with a secondary aim of providing a profile of internal and external rotation strength in a competitive surfing cohort. Shoulder internal rotation and external rotation isometric strength was measured using a hand-held dynamometer in 13 competitive surfers. Intra-class coefficient values ranged from 0.97 to 0.98 for intra-rater reliability and were lower for inter-rater reliability ranging from 0.80 to 0.91. Internal rotation strength was greater than external rotation strength bilaterally (dominant, p = 0.007, non-dominant, p < 0.001). No differences (p < 0.79) were found in internal rotation strength between the dominant and non-dominant arms. External rotation strength was weaker on the non-dominant arm compared with the dominant arm (p < 0.02). The non-dominant arm external rotation to internal rotation ratio (0.82 ± 0.15) was lower (p = 0.025) than the dominant arm (0.88 ± 0.14). The current procedure is reliable with the same clinician, and results indicate musculature asymmetry specific to the external rotators.

Patients who are candidates for subacromial decompression have more pronounced range of motion deficits, but do not differ in self-reported shoulder function, strength or pain compared to non-candidates.

Subacromial impingement syndrome (SIS) is associated with low self-reported shoulder function, impairments in shoulder strength and range of motion (ROM), and pain. It is not known how the symptomatology associated with SIS is reflected in the choice of treatment. This study compares self-reported shoulder function, shoulder strength, ROM, and pain in patients with SIS considered candidates and non-candidates for subacromial decompression (SAD). Self-reported shoulder function (Q-DASH and SPADI), maximum isometric muscle strength in shoulder abduction (Abd-strength) and external rotation (ER-strength), active abduction ROM (Abd-ROM) and passive internal rotation ROM (IR-ROM) were measured in a consecutive cohort of patients with SIS referred to an orthopedic outpatient clinic. Additionally, pain during each test and pain levels during the last week were reported. Patients were categorized as candidates or non-candidates for SAD based on their consultation with an orthopedic specialist blinded to test results and self-reported shoulder function. All outcomes and age, gender, weight and duration of symptoms were compared using the unpaired t test or Mann-Whitney's U test as appropriate. One-hundred and fifty-seven patients were included. 25 patients were candidates for SAD, while 132 were not. SAD candidates had significantly lower Abd-ROM (87° vs. 112°, p = 0.011, effect size = 0. 15) and IR-ROM (114° vs. 123°, p = 0.026, effect size = 0.58) additional to higher pain during test of Abd-strength (5.3 vs. 3.7, p = 0.02, effect size = 0.21). No other differences were found between the groups. A decrease in abduction and internal rotation range of motion, and increased pain during maximal abduction strength effort are associated with being considered a candidate for subacromial decompression, while self-reported shoulder function, pain during the last week, and rotator cuff strength are not. As SAD candidates primarily differentiates from non-candidates by having more pronounced ROM deficits, it might be important to address ROM in pre- and postsurgical evaluations, but as the overall differences between the two groups seem minor, the relation between impairments and the choice of treatment needs further clarification. IV.

The effects of posterior shoulder stretch on rotator cuff strength ratio in adolescent baseball players with scapular dyskinesis: A randomized controlled trial

The effects of posterior shoulder stretch on rotator cuff strength ratio in adolescent baseball players with scapular dyskinesis: A randomized controlled trial

Subacromial Local Anesthetics Do Not Interfere With Rotator Cuff Healing After Arthroscopic Repair

Background: Subacromial pain pumps are used for analgesia after arthroscopic rotator cuff surgery. However, there is controversy about myotoxic or tendinotoxic effects of local anesthetics. Hypothesis: Ropivacaine administered via a subacromial pain pump would have no adverse effect on rotator cuff tendon healing, fatty degeneration, strength, or functional outcomes after arthroscopic repair. Study Design: Cohort study; Level of evidence, 3. Methods: This study continues follow-up of patients enrolled in the authors’ 3 published prospective studies regarding pain control after arthroscopic rotator cuff repair. In total, 118 patients who underwent rotator cuff repair and returned for evaluation at least 1 year postoperatively were divided into 3 groups: patients who received continuous subacromial ropivacaine infusion (group 1, n = 33), those who received patient-controlled subacromial ropivacaine infusion (group 2, n = 30), and those who received other pain control modalities (intravenous patient-controlled analgesia and/or interscalene block; group 3, n = 55). At least 1 year postoperatively, tendon healing and changes in global fatty degeneration index (GFDI) were estimated through computed tomographic arthrography, magnetic resonance imaging, or ultrasonography. Changes in isokinetic muscle performance test (IMPT) were calculated and functional outcomes evaluated, including visual analog scales (VASs) for pain and satisfaction, American Shoulder and Elbow Surgeons score, and Constant score. Results: At final follow-up, there were no differences in pain VAS (group 1, 1.1 ± 2.3; group 2, 1.3 ± 1.9; group 3, 0.9 ± 1.7; P = .88), satisfaction VAS (group 1, 8.3 ± 2.4; group 2, 8.7 ± 1.5; group 3, 8.0 ± 2.1; P = .64), American Shoulder and Elbow Surgeons score (group 1, 79.5 ± 10.5; group 2, 81.1 ± 6.9; group 3, 75.7 ± 7.6; P = .34), or Constant score (group 1, 81.8 ± 8.7; group 2, 77.6 ± 9.3; group 3, 78.2 ± 8.4; P = .31). Among the 3 groups, there were no significant differences in healing rates (group 1, 72.7%; group 2, 73.3%; group 3, 70.9%; P = .83) and no differences in changes of GFDI (group 1, 0.45; group 2, 0.62; group 3, 0.41; P = .79), and IMPT (abduction: group 1, 113.0%; group 2, 121.5%; group 3, 120.1%; P = .73; external rotation: group 1, 112.1%; group 2, 121.6%; group 3, 111.7%; P = .71; internal rotation: group 1, 118.2%; group 2, 118.0%; group 3, 118.1%; P = .95). When data were reanalyzed with 2 groups (group 1 + 2 vs group 3), there were no significant differences in functional scores, healing rates, or changes in GFDI and IMPT (P > .05). Conclusion: Current data suggest that myotoxicity of subacromial ropivacaine administered via pain pump may be reversible or may not be so severe as to interfere with tendon healing and cause muscle degeneration and thus may not affect postoperative function.

Prevalence of Glenohumeral Internal Rotation Deficit and its Association with Scapular Dyskinesia and Rotator Cuff Strength Ratio in Collegiate Athletes Playing Overhead Sports

Introduction: Glenohumeral Internal Rotation Deficit (GIRD) indicates a 15° or greater loss of internal rotation of the throwing shoulder compared with the non-dominant shoulder.Aim: To estimate the prevalence of GIRD in collegiate overhead sports player and determine whether GIRD is associated with scapular dyskinesia and rotator cuff strength ratio. Materials and Methods: The present study was a Cross-sectional study. A total of 127 collegiate athletes were assessed for passive range of motion, external to internal rotation strength ratio (ER/IR ratio) and scapular dyskinesia for the throwing and non-throwing shoulder. Internal and external rotation of shoulder was measured using an inclinometer with the subject in prone and arm abducted to 90°. Scapular dyskinesia was measured using Lateral Scapula Slide test (LSST) and external to internal rotator strength was measured using a held hand isometric dynamometer. Chi-square test was used to find the association between GIRD and scapular dyskinesia and rotator cuff strength ratio.Results: Prevalence of GIRD (n=37) was found to be 29.1%. GIRD was not found to be associated with Scapular dyskinesia (p=0.237) and ER/IR strength ratio (p=0.411).Conclusion: Prevalence of GIRD in collegiate athletes playing overhead sports was found to be 29.1% and there was no association of GIRD with scapular dyskinesia, rotator cuff strength ratio.

Pullout strength of cement-augmented and wide-suture transosseous fixation in the greater tuberosity

BackgroundObtaining strong fixation in low-density bone is increasingly critical in surgical repair of rotator cuff tears because of the aging population. To evaluate two new methods of improving pullout strength of transosseous rotator cuff repair in low-density bone, we analyzed the effects of 1) using 2-mm suture tape instead of no. 2 suture and 2) augmenting the lateral tunnel with cement. MethodsEleven pairs of osteopenic or osteoporotic cadaveric humeri were identified by dual-energy x-ray absorptiometry. One bone tunnel and one suture were placed in the heads of 22 specimens. Five randomly selected pairs were repaired with no. 2 suture; the other six pairs were repaired with 2-mm suture tape. One side of each pair received lateral tunnel cement augmentation. Specimens were tested to suture pullout. Data were fitted to multivariate models that accounted for bone mineral density and other specimen characteristics. FindingsTwo specimens were excluded because of knot-slipping during testing. Use of suture tape versus no. 2 suture conferred a 75-N increase (95% CI: 37, 113) in pullout strength (P<0.001). Cement augmentation conferred a 42-N improvement (95% CI: 10, 75; P=0.011). Other significant predictors of pullout strength were age, sex, and bone mineral density. InterpretationWe show two methods of improving the fixation strength of transosseous rotator cuff repairs in low-density bone: using 2-mm suture tape instead of no. 2 suture and augmenting the lateral tunnel with cement. These methods may improve the feasibility of transosseous repairs in an aging patient population.

Rotator cuff strength balance in glovebox workers

Gloveboxes are essential to the pharmaceutical, semi-conductor, nuclear, and biochemical industries. While gloveboxes serve as effective containment systems, they are often difficult to work in and present a number of ergonomic hazards. One such hazard is injury to the rotator cuff, a group of tendons and muscles in the shoulder, connecting the upper arm to the shoulder blade. Rotator cuff integrity is critical to shoulder health. This study compared the rotator cuff muscle strength ratios of glovebox workers to the healthy norm. Descriptive statistics were collected using a short questionnaire. Handheld dynamometry was used to quantify the ratio of forces produced for shoulder internal and external rotation. Results showed this population to have shoulder strength ratios significantly different from the healthy norm. Strength ratios were found to be a sound predictor of symptom incidence. The deviation from the normal ratio demonstrates the need for solutions designed to reduce the workload on the rotator cuff musculature in order to improve health and safety. Assessment of strength ratios can be used to screen for risk of symptom development. This increases technical knowledge and augments operational safety.

Clinical assessment of factors associated with subacromial shoulder impingement: a systematic review

Background: Physiotherapists commonly use orthopaedic special tests to reproduce subacromial shoulder impingement (SIS) pain by increasing compression or tension within the subacromial space. However, these tests do not differentiate between purported extrinsic and intrinsic mechanisms associated with SIS.Objective: To identify, and determine the reliability and validity of clinical tests used to assess extrinsic factors associated with SIS.Method: A scoping review identified tests for extrinsic SIS. A systematic approach was then used to search six electronic databases in July 2016 to identify clinical tests used to measure (1) posterior shoulder range, (2) cervical and/or thoracic posture, (3) 2D scapula movement, (4) rotator cuff strength. The 14 articles included in the review were assessed using a modified Downs and Black quality assessment tool.Results: Moderate quality studies investigated 2D scapula measurements (N = 2), resting pectoralis minor length (N = 2) and rotator cuff strength (N = 5). High quality studies measured forward head position and/or thoracic posture (N = 2) and rotator cuff strength (N = 1).Conclusion: A good level of assessment reliability and significantly less range and strength was identified in those with SIS for: posterior shoulder range (passive shoulder adduction and internal rotation and passive internal rotation in supine); isokinetic peak torque values for internal and external shoulder rotation (isokinetic testing); forward head position (lateral photograph) and thoracic range of motion (tape measure or ultrasound tomography). Good to excellent reliability was reported for lateral scapular slide test positions and resting pectoralis minor muscle length. These clinical tests should be considered for use in SIS assessment.

More Arthroscopic Solutions to Ornery Orthopaedic Problems.

The indications for arthroscopic treatment of musculoskeletal injuries continue to expand as orthopaedists find new and creative ways to apply this flexible technology. Our last “Case Connections” review of unique arthroscopic techniques was in November 2014, and, since then, several more exciting arthroscopy-related case reports in JBJS Case Connector suggested that it was time for an update. It’s exceedingly rare to see a patient with an isolated avulsion of the teres minor tendon without any concomitant rotator cuff or shoulder abnormality, but that’s exactly what Zaman and Syed describe in a case report in the May 25, 2016, edition of JBJS Case Connector. The patient was a 17-year-old female soccer player who presented 1 month after falling on an outstretched right arm. At the time of injury, she reported feeling a snap in the back of the right shoulder, and posterior pain and weakness persisted despite the use of a sling, activity modification, and physical therapy. On examination, the patient had full passive range of motion but displayed a positive hornblower sign, and active external rotation in adduction was painful and measured only 20°. Otherwise, the patient demonstrated good rotator cuff strength and a stable glenohumeral joint. An MRI scan of the right shoulder confirmed a posterior avulsion of the teres minor at its insertion onto the greater tuberosity. No other rotator cuff, labral, or osseous injuries were observed. Because the patient was young and active and wished to regain full function, surgeons performed arthroscopic operative repair of the teres minor. During standard diagnostic arthroscopy, surgeons cleared bursal tissue from the right subacromial space and the posterior and lateral recesses. After debridement, surgeons visualized the avulsed teres minor, along with a sleeve of periosteum from the greater tuberosity (Fig. 1). Further arthroscopic visualization of the rotator cuff and glenohumeral ligament …

Posterior Shoulder Pain in a High School Football Lineman

HISTORY: 16yo high school football lineman presented with right shoulder pain. He initially noticed moderate pain after squatting 350lbs and placing the weight back down. The pain was sharp and painful when turning his head to the left. He was evaluated at an urgent care facility and felt to have a muscular injury and placed on muscle relaxants and anti-inflammatories. His pain improved transiently. He then re-injured this area when he was in gym class running hurtles and brought his arms across his chest in the front of him. He states that he heard a pop in his shoulder and had excruciating pain, and presented to the sports medicine clinic for further evaluation. The pain was pleuritic and still localized to the posterior shoulder. PHYSICAL EXAMINATION: BMI 33.5RR 17O2 Sat 99% He appeared moderately uncomfortable. He had full motion at the neck with no tenderness of the cervical spine. Bending to the left was mildly painful. He had a negative Spurling’s maneuver. He had tenderness over the medial rhomboids, trapezius, and overlying the scapular body. He had no scapular winging. He had full range of motion at the shoulder and 5/5 rotator cuff strength. He had no AC tenderness or pain with cross arm adduction. His lung fields were clear to auscultation with good air movement throughout. DIFFERENTIAL DIAGNOSIS: 1. Strain or partial tear of scapular stabilizer 2. Snapping Scapula (scapulothoracic bursitis) 3. First Rib Fracture TEST AND RESULTS: Three views of the right shoulder (AP, scapular Y, and lateral axillary) -Nondisplaced, oblique fracture through mid-portion of the first right rib Two views of clavicles (AP and 15 degree cephalic) -Fracture confirmed; no pneumothorax is visualized FINAL WORKING DIAGNOSIS: 1st Rib Stress Fracture secondary to scalene and serratus anterior contraction TREATMENT AND OUTCOMES: 1. Patient was placed in sling and provided with narcotic analgesia; pendulum exercises were emphasized. 2. At three weeks, repeat XR showed minimal displacement of the fracture. His sling was discontinued and he was allowed to start back light weight training (30lbs max). Physical therapy was ordered. 3. At 7 weeks, he was pain free with normal strength and allowed to resume normal weight lifting. 4. At 3 month follow up, repeat XR showed some callus formation. He was allowed to resume contact sports, such as football.

All-Arthroscopic Modified Rotator Interval Slide for Massive Anterosuperior Cuff Tears Using the Subdeltoid Space: Surgical Technique and Early Results.

Traditional intra-articular arthroscopic repair techniques for massive anterosuperior rotator cuff tears are technically demanding and necessitate sacrifice of the rotator interval to enable visualization. An interval slide allows mobilization through release of the medial aspect of the rotator interval, while leaving the lateral, bridging fibers intact. The purpose of this study was to report a novel, arthroscopic, open-equivalent technique using the subdeltoid space to address these tears along with early clinical results. A retrospective review of prospectively collected data identified 11 consecutive arthroscopic massive anterosuperior rotator cuff repairs with a concomitant biceps tenodesis performed by the senior surgeon using a uniform technique. Outcome measures included range of motion, visual analog scale for pain, rotator cuff strength, American Shoulder and Elbow Surgeons (ASES) outcome scale, and Short Form-12 (SF-12). Average length of follow-up was 22.2months (range 12.5-30.0months). Visual analog scale (VAS) pain scores, ASES, and SF-12 all demonstrated significant improvement from pre-op to final follow-up from 6.2 to 0.9 (p < 0.05), 27.4 to 82.8 (p < 0.05), and 26.6 to 45.5 (p < 0.05) respectively. Average forward flexion improved from 145° to 160° (p < 0.05). Seven of the nine patients with a positive preoperative belly press had a negative test at final follow-up. Nine of the 10 patients with a positive lift off test demonstrated a negative test on final follow-up. Ninety-one percent reported they were satisfied with their outcome. The described modified all-arthroscopic subdeltoid approach for anterosuperior cuff repairs enabled an open-equivalent interval slide technique that preserved the bridging lateral fibers of the rotator interval and demonstrated promising early-term clinical results.

A probabilistic orthopaedic population model to predict fatigue-related subacromial geometric variability

Fatigue-related glenohumeral and scapulothoracic kinematic relationships, in addition to morphological characteristics of the scapula and humerus, affect the dimensions of the subacromial space. Each exhibits considerable interpersonal variability, which if only considering the mean, can lead to misleading population estimations of subacromial impingement risk, particularly for outliers. Additionally, the relative influence of each parameter on subacromial space variability is unclear. Applying empirically-derived morphological and kinematic distributions (n=31), this research used Advanced Mean Value and Monte Carlo probabilistic modeling approaches to predict the distribution of the minimum subacromial space width (SAS) and establish which parameters contributed more to modulating the SAS. The predicted SAS differed by 8mm between 1% and 99% confidence intervals. While the SAS was not influenced by muscle fatigue, the space reduced with arm elevation to magnitudes between 4.5 and 5mm. This reduction resulted in an estimated 65–75% of the population at risk for tissue compression at elevation angles≥90° when considering the interposed tissue thickness. Morphological parameters, notably glenoid inclination, showed higher relative importance for modulating the predicted SAS across conditions, while kinematic parameters (humeral head translation, scapular orientation), which differed by elevation angle and fatigue state, demonstrated less consistent importance levels across experimental conditions. Overall, the findings reinforce the shoulder health risks related to overhead activities, as they pose an increased likelihood of mechanical rotator cuff tendon compression. Further, probabilistic methods are highly innovative, in that they are capable of determining relative parameter importance and subsequently identifying key injury risk factors. As glenoid inclination is difficult to diagnose and treat, and is associated with superior humeral head translation, interventions to improve rotator cuff strength and glenohumeral stability are recommended, particularly in populations exposed to overhead postures.

Evidence-based rehabilitation of athletes with glenohumeral instability.

To give an overview of current knowledge and guidelines with respect to evidence-based rehabilitation of athletes with glenohumeral instability. This narrative review combines scientific evidence with clinical guidelines based on the current literature to highlight the different components of the rehabilitation of glenohumeral instability. Depending on the specific characteristics of the instability pattern, the severity, recurrence, and direction, the therapeutic approach may be adapted to the needs and demands of the athlete. In general, attention should go to (1) restoration of rotator cuff strength and inter-muscular balance, focusing on the eccentric capacity of the external rotators, (2) normalization of rotational range of motion with special attention to the internal rotation ROM, (3) optimization of the flexibility and muscle performance of the scapular muscles, and (4) gradually increasing the functional sport-specific load on the shoulder girdle. The functional kinetic chain should be implemented throughout all stages of the rehabilitation program. Return to play should be based on subjective assessment as well as objective measurements of ROM, strength, and function. This paper summarizes evidence-based guidelines for treatment of glenohumeral instability. These guidelines may assist the clinician in the prevention and rehabilitation of the overhead athlete. Expert opinion, Level V.

Asymptomatic Elite Adolescent Tennis Players' Signs of Tendinosis in Their Dominant Shoulder Compared With Their Nondominant Shoulder.

Tennis is an asymmetric overhead sport with specific muscle-activation patterns, especially eccentrically in the rotator cuff. Magnetic resonance imaging (MRI) findings in asymptomatic adolescent elite tennis players have not previously been reported. The first aim of the study was to describe MRI findings regarding adaptations or abnormalities, as well as muscle cross-sectional area (CSA), of the rotator cuff. The second aim of the study was to investigate the rotator cuff based on the interpretation of the MRI scans as normal versus abnormal, with the subdivision based on the grade of tendinosis, and its association with eccentric rotator cuff strength in the dominant arm (DA) of the asymptomatic elite adolescent tennis player. Testing environment at the radiology department of Medicinsk Röntgen AB. Thirty-five asymptomatic elite tennis players (age = 17.4 ± 2.7 years) were selected based on ranking and exposure time. We assessed MRI scans and measured the CSA of the rotator cuff muscle. The non-DA (NDA) was used as a control. In addition, eccentric testing of the external rotators of the DA was performed with a handheld dynamometer. The DA and NDA displayed different frequencies of infraspinatus tendinosis (grade 1 changes) (P < .05). Rotator cuff measurements revealed larger infraspinatus and teres minor CSA (P < .05) in the DA than in the NDA. Mean eccentric external-rotation strength in the DA stratified by normal tendon and tendinosis was not different between groups (P = .723). Asymptomatic adolescent elite tennis players demonstrated infraspinatus tendinosis more frequently in the DA than in the NDA. Clinicians must recognize these tendon changes in order to modify conditioning and performance programs appropriately.

Eccentric and isometric shoulder rotator cuff strength testing using a hand-held dynamometer: reference values for overhead athletes.

In order to provide science-based guidelines for injury prevention or return to play, regular measurement of isometric and eccentric internal (IR) and external (ER) rotator strength is warranted in overhead athletes. However, up to date, no normative database exists regarding these values, when measured with a hand-held dynamometer. Therefore, the purpose of the study was to provide a normative database on isometric and eccentric rotator cuff (RC) strength values in a sample of overhead athletes, and to discuss gender, age and sports differences. A HHD was used to measure RC strength in 201 overhead athletes between 18 and 50years old from three different sports disciplines: tennis, volleyball and handball. Isometric as well as eccentric strength was measured in different shoulder positions. Outcome variables of interest were isometric ER and IR strength, eccentric ER strength, and intermuscular strength ratios ER/IR. Our results show significant side, gender and sports discipline differences in the isometric and eccentric RC strength. However, when normalized to body weight, gender differences often are absent. In general, strength differences are in favour of the dominant side, the male athletes and handball. Intermuscular ER/IR ratios showed gender, sports, and side differences. This normative database is necessary to help the clinician in the evaluation of RC strength in healthy and injured overhead athletes. In view of the preventive screening and return-to-play decisions in overhead athletes, normalization to body weight and calculating intermuscular ratios are key points in this evaluation. Diagnostic study, Level III.

Predictive Value Of Preseason Screening In Collegiate Baseball Pitchers

Objectives:High level baseball pitchers are prone to shoulder and elbow injuries, resulting in significant morbidity and missed time from sport. This is the first study to use both subjective and objective preseason evaluations of baseball pitchers to predict injuries that occur in-season. We hypothesize that athletes reporting unfavorable scores on subjective questionnaires, and athletes falling outside the established pre-season normative values for objective data are more likely to develop injuries in season.Methods:Over three collegiate baseball seasons from 2011 through 2013, a cohort of collegiate Division I baseball pitchers underwent both objective and subjective evaluation prior to the start of the fall collegiate season. Preseason analysis included range of motion (ROM) in 5 planes, upper extremity manual muscle testing (MMT), Functional Movement Screen (FMS) assessment, a Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder and Elbow score, an Upper Extremity Patient History (UEPH) questionnaire, and a Modified American Shoulder Elbow Score (MASES) questionnaire. This cohort was monitored over the course of the subsequent season for the development of injury and missed game time. A descriptive analysis for each questionnaire and all objective variables was performed. Univariate and multivariate regression models were used to explore potential risk factors for upper extremity (UE) injuries. Scatter plots, Spearman's correlation coefficients, and corresponding p-values were used to examine the relationship between subjective responses, objective physical parameters, and injury days missed.Results:Forty-two athletes participated in the study over three consecutive collegiate baseball seasons. Our preseason normative values for ROM, MMT, and the KJOC questionnaire are shown in Tables 1, 2, and 3. The mean KJOC score for our cohort was 86.93/100 (SD 12.49), and the mean MASES score was 88.4/100 (SD 21.7). The mean FMS score in our cohort was 15/21 (SD 3). Injury data for our cohort are shown in Table 4. After three full seasons, a lower KJOC score significantly correlated with injury days missed (Spearman's rho = 0.63, P-value 0.0122). Through the first two seasons, pitchers with a 1% higher UE rating on the UEPH questionnaire had 9.5% lower odds of developing injury during the season (OR 0.9149, 95% CI 0.8525-0.9819, P Value 0.014). Pitchers reporting every 1 unit higher of subjective instability had 61.27% higher odds of developing an UE injury (OR 0.6127, 95% CI 1.1044-2.3549, P value 0.013). However, by the end of the third season, and after adjusting for the use of pain medication, these variables failed to reach significance in our multiple regression analysis. Dominant shoulder TAM, rotator cuff strength, and glenohumeral internal rotation deficit (GIRD) were not predictive of injury in our cohort; although having over 5 degrees of difference in TAM vs the non-dominant shoulder approached significance (P-value 0.0598).Conclusion:This is the first study to demonstrate predictive value of subjective questionnaires. The KJOC Overhead Athlete Shoulder and Elbow Score can be used as part of the standardized preseason athlete evaluation to target pitchers at risk for developing injuries in-season. Objective parameters - notably TAM, GIRD, and rotator cuff strength - were not predictive of injuries in our cohort, which contradicts prior reports. To our knowledge, normative FMS data has not yet been established in baseball pitchers.

Isokinetic Rotator Cuff Functional Ratios and the Development of Shoulder Injury in Collegiate Baseball Pitchers

Context:Shoulder injury in baseball pitchers is a very common problem and has been linked to an imbalance in rotator cuff strength. Recently, the use of functional shoulder strength ratios has become more popular because they more closely resemble the actions of the shoulder during the throwing motion.Objective:To investigate the link between preseason shoulder rotator cuff functional strength ratios and the development of shoulder pain and injury.Design:Prospective research design.Setting:University human performance laboratory.Patients:Fifteen collegiate baseball pitchers participated in this study. At the end of the baseball season, six (19.5 ± 1.8 years, 73.6 ± 2.8 inches, 198.7 ± 19.1 lbs) developed shoulder injury and were placed in the injured group, and nine (21.0 ± 1.7 years, 73.1 ± 2.3 inches, 207.9 ± 28.1 lbs) did not develop injury and were placed in the noninjured group.Interventions:Isokinetic peak torque was collected concentrically and eccentrically for both shoulder internal rotation (IR) and external rotation (ER) at 60°-s−1, 180°-s−1, and 300°-s−1.Main Outcome Measure:The following functional ratios were calculated from the peak torque measures: concentric ER: concentric IR; eccentric ER: eccentric IR; concentric ER: eccentric IR (cocking phase); and eccentric ER: concentric IR (acceleration phase). Analysis was conducted using an analysis of variance comparing the injured and noninjured groups. A secondary analysis was conducted using an analyses of variance on the concentric and eccentric peak torque for shoulder IR and ER between groups.Results:The acceleration phase functional shoulder ratio was significantly higher (p = .019) in the injured group and a concentric IR peak torque (p = .003) was significantly lower in the injured group compared with the noninjured group.conclusion:Increased acceleration phase ratios and decreased concentric IR peak torque may be linked to the development of shoulder injury during a baseball season.

Shoulder Injury - Motor Vehicle Accident in a Tennis Player

HISTORY: A 31-year-old male tennis player and musician was in motor vehicle accident. He was the restrained driver, flipped upside down hanging by seatbelt, no airbag deployment. Developed left shoulder pain with electricity sensation and a pulsing sensation near left midshaft clavicle. PHYSICAL EXAM: No tenderness of sternoclavicular or acromioclavicular joint, clavicle. Flexion and abduction 0-180 degrees, external rotation 0-90 degrees, internal rotation to T6. Negative Jobe’s, Neer’s and Hawking’s. Full strength of rotator cuff. Mild tenderness to palpation and thrill of left subclavian artery superior to midshaft clavicle. Positive Wright’s and Roos. Negative Spurling, Lhermitte, Naffziger sign. Hypoesthesia to anterior cervical triangle. DIFFERENTIAL DIAGNOSIS: 1. arteriovenous malformation of subclavian artery 2. thoracic outlet syndrome 3. pseudoaneurysm 4. subclavian artery thrombus 5. clavicle fracture 6. brachial plexopathy TESTS AND RESULTS: - XR left clavicle (2 weeks): No acute fracture. Mild deformity of left first rib, more suggestive of old trauma. - MRI L brachial plexus (2 weeks): Mild left brachial plexus edema suggesting mild neuritis or stretching injury. - CT neck and chest with IV contrast (10 weeks): No soft tissue mass noted at left supraclavicular region. There is fracture at 1st rib with superior angulation of the fracture site deep to the area of interest. - office ultrasound (12 weeks): L subclavian artery 7mm x 3.8cm, corresponds to patient’s location of pain. - vascular ultrasound (15 weeks): no evidence of subclavian artery aneurysm. - CT angiography chest (16 weeks): Pseudoarthrosis of hypoplastic left first rib with lateral second rib. Pseudoarticulation abuts undersurface of mid left subclavian artery without significant extrinsic compression. Left subclavian artery is slightly dilated with questionable surrounding stranding, may suggest stretch injury. No aneurysm or dissection. FINAL/WORKING DIAGNOSIS: left subclavian artery shear/stretch injury TREATMENT/OUTCOME Initially treated with rest and NSAIDs. About 4 weeks post-injury, 7-day course of prednisone 50mg given for brachial plexus injury. Physical therapy started at 13 weeks to stretch scalenes, pectoralis minor, first rib glide. Has not yet returned to activity (at time of submission).

Left Shoulder Pain - Football

HISTORY: A 13 year old football player reported the insidious onset of left shoulder pain over a three month period. The pain began after lifting weights and slowly worsened. It was described as aching and located over the posterior shoulder. The pain was made worse by rotating and abducting the arm and improved with rest. The pain radiated to the upper arm. The patient reported one episode of numbness and tingling in his left arm. He denied any persistence of these symptoms and reported no subjective weakness. PHYSICAL EXAMINATION: Exam of the left shoulder revealed limited active flexion, abduction, and external rotation at the extremes of range of motion secondary to pain. Rotator cuff strength testing on the left revealed weakness and pain throughout, particularly with external rotation. There was also 2+ anterior and posterior instability noted with a positive apprehension and relocation test. The patient was neurovascularly intact to his bilateral upper extremities. There was no supraclavicular or axillary lymphadenopathy. The exam was otherwise normal. DIFFERENTIAL DIAGNOSIS: 1. Rotator cuff strain/tendinitis 2. Shoulder instability/subluxation 3. Scapular dysfunction 4. Bony lesion of the scapula TESTS AND RESULTS: Left shoulder radiographs: -Permeative lesion in the scapular body that extended from the base of the supraspinatus fossa inferiorly to within 3.5 cm of the inferior angle of the scapula. The lesion had ill-defined boundaries and a wide zone of transition. Left scapula MRI with and without contrast: -Lesion in scapula redemonstrated. In greatest dimension, it measured 2.8 cm by 3.2 cm by 5.6 cm with a soft tissue mass extending into the infraspinatus and teres minor. Overall appearance of the lesion was most concerning for an aggressive etiology such as Ewing’s sarcoma or osteosarcoma, though other bony tumors remained in the differential. CT guided biopsy: -Pathology was consistent with eosinophilic granuloma (Langerhan’s cell histiocytosis). FINAL/WORKING DIAGNOSIS: Localized eosinophilic granuloma of the left scapula TREATMENT AND OUTCOMES: 1. Patient is currently undergoing treatment at a tertiary care center (awaiting updated records). 2. Patient is being held out of football currently.

Prevention of shoulder injuries in overhead athletes: a science-based approach.

The shoulder is at high risk for injury during overhead sports, in particular in throwing or hitting activities, such as baseball, tennis, handball, and volleyball. In order to create a scientific basis for the prevention of recurrent injuries in overhead athletes, four steps need to be undertaken: (1) risk factors for injury and re-injury need to be defined; (2) established risk factors may be used as return-to-play criteria, with cut-off values based on normative databases; (3) these variables need to be measured using reliable, valid assessment tools and procedures; and (4) preventative training programs need to be designed and implemented into the training program of the athlete in order to prevent re-injury. In general, three risk factors have been defined that may form the basis for recommendations for the prevention of recurrent injury and return to play after injury: glenohumeral internal-rotation deficit (GIRD); rotator cuff strength, in particular the strength of the external rotators; and scapular dyskinesis, in particular scapular position and strength.