Symptomatic Shoulder Research Articles

Subscapularis tendinopathy is highly prevalent in elite swimmer's shoulders: an MRI study

ObjectivesThe aim of this study is to determine the prevalence of abnormal anatomical change present on MRI in elite swimmers' shoulders compared to age-matched controls. DesignDescriptive epidemiological study. MethodsSixty (aged 16–36 years) elite Australian swimmers and 22 healthy active, age and gender matched controls (aged 16–34 years). All participants completed a demographic, and training load and shoulder pain questionnaire and underwent shoulder MRI. Tests for differences in the population proportion was used for comparison between swimmers dominant and non-dominant shoulders and those of the controls. ResultsSubscapularis and supraspinatus tendinopathy was the most common tendon abnormality identified in swimming participants, being reported in at least one shoulder in 48/60 (73 %) and 46/60 (70 %) swimmers, respectively. There was no significant difference between dominant and non-dominant shoulders for either tendinopathy, however, grade 3 tendinopathy was significantly more prevalent in subscapularis than in supraspinatus (P < 0.01). Compared with controls, significantly more abnormalities were reported in swimmers' shoulders in both subscapularis and supraspinatus tendons along with the labrum and acromioclavicular joint. Pathology was not a predictor of current pain. ConclusionsThis data confirms that tendon abnormality is the most common finding in elite swimmers' shoulders. Furthermore, that subscapularis tendinopathy is not only as common as supraspinatus but has a greater prevalence of grade 3 tendinopathy. With significant varied abnormalities including tendinopathy being so common in both symptomatic and asymptomatic shoulders of swimming athletes', clinicians should consider imaging findings alongside patient history, symptom presentation and clinical examination in determining their relevance in the presenting condition.

The effect of steroid injection into the shoulder on glycemia in patients with type 2 diabetes.

BackgroundInjections of corticosteroids into or around joints have been reported to increase blood glucose in patients with diabetes due to corticosteroid absorption into the bloodstream. However, the magnitude, duration, and clinical implications of local corticosteroid injections on glycemic control are not clear. The purpose of this study was to evaluate the effects of corticosteroid injection to the shoulder on glycemia in patients with type 2 diabetes mellitus using a continuous glucose monitoring device.MethodsTwenty-five patients with symptomatic shoulder problems and type 2 diabetes mellitus, not treated with insulin, prescribed a corticosteroid injection into the shoulder, were investigated. The patients were connected to a flash glucose monitoring system, which continuously monitored interstitial glucose levels. Data were collected 3 days before injection and for additional 11 days after corticosteroid injection. We analyzed glucose levels in the first 3 days (early postinjection) and on days 4-11 (late postinjection) after the injection and compared them to the preinjection period. The outcome measures included change in the average glucose levels, per patient, between the preinjection and postinjection periods and the differences in the time spent at glucose >180 mg/dL, >250 mg/dL, and >350 mg/dL, per patient, between the preinjection and postinjection periods.ResultsThe increase in the mean glucose level per patient was statistically significant from 136 mg/dL in the preinjection period to 159 mg/dL in the first 3 days after the injection and returned to normal thereafter. Time at blood glucose >250 mg/dL increased from 4.3% in the preinjection period to 9.5% on the first day after the injection. It then decreased to 7% on day 2, 3.8% on day 3, and 1.4% in the late postinjection period. New onset of glucose levels >350 mg/dL was found in 4 of 25 patients during the early postinjection period. In all 4 patients, the exposure to severe hyperglycemia (>350 mg/dL) was short. None of the patients required intensification of the antidiabetic treatment or insulin injections.ConclusionLocal corticosteroid injection to the shoulder can create a significant, short-term increase in systemic glucose levels in patients with D2DM not treated with insulin. Some of these patients may have periods with glucose above 350 mg %. However, these glycemic changes are short lived and are mostly limited to the 2-3 days after the injection. In addition, none of the patients in our study needed any change in antidiabetic treatment or any medical care after the injection.

Cross-cultural Adaptation and Validation of the European Portuguese Version of the Western Ontario Shoulder Instability Index (WOSI).

The Western Ontario Shoulder Instability Index (WOSI) is a self-administered questionnaire specifically used to determine the impact of shoulder instability on quality of life. The aim of this study was to translate the WOSI into European Portuguese and analyze its validity and reliability in a population with shoulder instability. The WOSI was translated and culturally adapted from its original version into European Portuguese (WOSIPT). Internal consistency and test-retest analyses were conducted to determine the level of reliability of the scale. WOSI-PT, Quick-DASH, and SF-12 questionnaires were applied to 81 patients with symptomatic shoulder instability to assess validity, and reliability was tested by randomly selecting 50 patients within 72 hours using a test-retest design. The reliability of the WOSI-PT was very high, with Cronbach´s alpha equal to 0.97 and an intraclass correlation coefficient of 0.98. Regarding the construct validity, the correlation between the WOSI-PT and QuickDASH was high and negative (-0.79). The correlations between WOSI-PT and SF-12 were positive, respectively, moderate with physical (0.66) and low with mental (0.34) health. WOSI-PT is a reliable and valid instrument for assessing the functional impact of shoulder joint instability on quality of life.

Poster 174: The Role of Familial Predisposition in Imaging-Confirmed Atraumatic Rotator Cuff Tears

Objectives:The etiology of rotator cuff tears is not completely understood. Several studies have identified age, smoking, hypercholesterolemia, diabetes, and hypertension as potential risk factors of rotator cuff tears. Limited data suggests the role of genetic and familial predisposition in the etiology of rotator cuff tears. Our objective was to assess whether there is an increased likelihood of rotator cuff tears in family members of patients with rotator cuff tears versus those without tears. This would provide evidence for whether there is a familial predisposition to rotator cuff tears.Methods:Patients presenting to a shoulder clinic with pain, stiffness, or instability were recruited in this study. Patients that completed a shoulder outcomes questionnaire, were age 18 years or older, and had an available MRI or CT arthrogram of the symptomatic shoulder were included in the study. Any individuals with acute traumatic rotator cuff tears were excluded from analysis. On the questionnaire, patients provided information on demographics, personal medical history, shoulder symptoms, and family history of rotator cuff tears. The diagnosis of rotator cuff tears was based on imaging (MRI or CT arthrogram) confirmation of a structural defect in the rotator cuff. The association between family history of rotator cuff problems and the likelihood of an imaging-confirmed rotator cuff tear diagnosis was evaluated using multivariate logistic regression, adjusting for age, sex, race and ethnicity, smoking, hypertension, diabetes, and depression.Results:In our cohort of 2,337 patients, 52.7% (n=1,231) of patients had an imaging-confirmed atraumatic rotator cuff tear. Among patients with tears, 18.0% (n=221) of patients reported a family history of rotator cuff issues versus 11% (n=123) in patients without tears. A family history of rotator cuff problems was significantly associated with the diagnosis of an imaging-confirmed rotator cuff tear (Odds Ratio=2.27, 95% CI = 1.72, 3.01). Increasing age (Odds Ratio=1.06, 95% CI = 1.05, 1.07) and Hispanic race and ethnicity (Odds Ratio=1.49, 95% CI = 1.06, 2.11 in Hispanic patients versus those of Non-Hispanic White ancestry) were also significantly associated with a rotator cuff tear diagnosis. Sex, smoking, hypertension, diabetes, and depression were not significantly associated with rotator cuff tears.Conclusions:Our study shows that individuals with rotator cuff tears were over two times as likely to have a family member with a rotator cuff tear as compared with patients without tears. These results support previous studies which have suggested a genetic component in the development of tendinopathies1.In a similar study by Assunção et al., individuals with familial history of treatment for rotator cuff tears were 3.3 times as likely to experience a cuff tear2. In another study by Harvie et al, siblings of patients with a full-thickness tear were 2.42 times more likely to experience a tear

Can the Scapular Dyskinesis Test be Associated with Throwing Related Injuries During the Course of Collegiate Baseball Seasons?

BackgroundA pattern of scapular dyskinesis on the dominant side has been demonstrated to be associated with a decrease in throwing arm conditions identified by a self-report outcome assessment in collegiate baseball pitchers during the course of a single season. However, it is unclear if symptomatic shoulders in baseball pitchers may be associated with the presence of scapular dyskinesis.PurposeTo study the relationship between the presence of scapular dyskinesis and throwing-related injury in collegiate baseball pitchers during each respective course of up to four subsequent seasons.MethodsA single Division 1 National Collegiate Athletic Association team participated in this study over a four-year-period. The scapular dyskinesis test was implemented during the preseason for baseball pitchers. Players were followed throughout each respective season to track the incidence of throwing-related upper extremity injuries.ResultsA total of 36 collegiate baseball pitchers (height: 185.3 ± 5.6 cm, weight: 88.8 ± 7.8 kg, age: 20.0 ± 1.5 years) consisting of 57 pitcher seasons were followed in this study, in which 18 pitchers remained with the team for more than one year. Twenty-seven of the 57 pitchers were classified as having scapular dyskinesis demonstrated at around 90° of shoulder flexion on the throwing side. Five injuries (13.2% of a total of 38 injuries) were diagnosed as throwing-related shoulder injuries during the course of the intercollegiate baseball seasons. Four of the five throwing-related shoulder injuries occurred in pitchers who had scapular dyskinesis on their dominant side. Consequently, the odds ratio was 5.04 for the collegiate pitchers with scapular dyskinesis on the throwing arm side associated with a throwing-related shoulder injury compared to those with no scapular dyskinesis (p = 0.16). No relationship was identified between scapular dyskinesis on the throwing arm side and throwing-related elbow injury. Eighty-one percent of the scapular dyskinesis test results were not changed on the throwing side from the previous to the following year for those 18 pitchers who were followed for more than one season, whereas 42.9% of the results remained unchanged on the non-throwing side.ConclusionThe results suggest that collegiate baseball pitchers with dominant arm scapular dyskinesis likely are at increased risk of throwing-related shoulder injury.Level of evidenceLevel 2, Prospective Cohort Study

Determining the outcomes after shoulder surgery

Measurement of the outcome following shoulder surgery often demonstrates the discrepancy between the surgeon's perceptions and those of the patient. Therefore, it has been recognized that it is no longer acceptable to present purely surgeon-reported outcomes for shoulder surgery. As the number of shoulder procedures performed worldwide has increased in recent years, so has the necessity to measure performance. A combination of patient-reported outcome measures (PROMs), surgeon-reported outcomes and, for arthroplasty, national registry data is now commonly presented to quantify any change following intervention for a symptomatic shoulder joint. However, as the shoulder is a complex entity itself, involving a number of joints and possible pathologies, it can be difficult to comprehend whether a certain measure is being used appropriately. The aim of this article is to highlight the most frequently used outcome scores, including PROMs and national shoulder registries, discussing what they aim to measure, their strengths, limitations, specificity to pathology or procedure and cautions for bias.

Risk factors for degenerative, symptomatic rotator cuff tears: a case-control study.

Despite the considerable public health burden of rotator cuff tears, there is no consensus on risk factors associated with symptomatic rotator cuff tears. In this study, a large data source was used to identify factors associated with symptomatic rotator cuff tears. We defined cases of rotator cuff tears as those verified by imaging or operative reports and controls as symptomatic shoulders without rotator cuff tears as verified by imaging or operative reports. We performed a case-control study of patients with and without symptomatic rotator cuff tears by use of the Vanderbilt University Medical Center de-identified electronic medical record system, the Synthetic Derivative, with records on >2.5 million patients from 1998 to 2017. Cases and controls were confirmed by individual chart review and review of imaging and/or operative notes. A final set of 11 variables were analyzed as potential risk factors for cuff tears: age, sex, body mass index (BMI), race, smoking history, hypertension, depression/anxiety, dyslipidemia, carpal tunnel syndrome, overhead activity, and affected side. Multivariable logistic regression was used to estimate the association between predictor variables and the risk of having a rotator cuff tear. A total of 2738 patients were selected from the Synthetic Derivative, which included 1731 patients with rotator cuff tears and 1007 patients without rotator cuff tears. Compared with individuals without tears, those with rotator cuff tears were more likely to be older (odds ratio [OR], 2.44; 95% confidence interval [CI], 2.12-2.89), to have a higher BMI (OR, 1.45; 95% CI, 1.24-1.69), to be of male sex (OR, 1.56; 95% CI, 1.32-1.85), and to have carpal tunnel syndrome (OR, 1.41; 95% CI, 1.03-1.93). Patients with rotator cuff tears were less likely to have left shoulder symptoms (OR, 0.68; 95% CI, 0.57-0.82) and to have depression/anxiety (OR, 0.77; 95% CI, 0.62-0.95) compared with the control group, which had symptomatic shoulder pain without rotator cuff tears. In a large imaging and operative report-verified case-control study, we identified advancing age, male sex, higher BMI, and diagnosis of carpal tunnel syndrome as risk factors significantly associated with an increased risk of rotator cuff tears. Left shoulder symptoms and depression/anxiety were less likely to be associated with rotator cuff tears compared with symptomatic shoulders without rotator cuff tears. Contrary to some prior reports in the literature, smoking was not associated with rotator cuff tears.

Anterior Glenohumeral Capsularligament Reconstruction for Internal Impingement of the Shoulder in Baseball Players

Surgical management of internal impingement in throwing athletes remains challenging. This study aimed to investigate anterior glenohumeral capsularligament reconstruction (AGCR) with hamstring autograft in throwing athletes. Twelve male competitive throwing athletes with AGCR were studied (mean age, 21; 10 right and 2 left AGCRs). All athletes participated in baseball (seven pitchers and five fielders). Inclusion criteria were symptomatic dominant shoulder pain in the abduction and maximum external rotation, failed conservative treatment, and anterior instability.

Arthroscopic release of the pectoralis minor tendon as an adjunct to acromioplasty in the treatment of subacromial syndrome associated with scapular dyskinesia

IntroductionOne of the causes of scapular dyskinesia is the retraction of the pectoralis minor muscle. It can be the cause of shoulder pain associated with increased anterior tilt and internal rotation of the shoulder. HypothesisArthroscopic release of the pectoralis minor tendon is effective for shoulder pain, linked to a correction of dyskinesia, resulting in the early disappearance of scapulalgia. Patients and methodsThis was a retrospective, monocentric, single-surgeon study on a continuous series of patients with symptomatic shoulder pain, related to subacromial impingement associated with scapular dyskinesia. The series underwent arthroscopic tenotomies of the pectoralis minor between January 2015 and September 2018. Fifty-eight releases were performed to 57 patients (22 males, 35 females), with a mean age of 51.4 years (29–66 years). In all cases, they presented pain on palpation of the upper bundle of the trapezius muscle, and on palpation of the coracoid insertion of the pectoralis minor. ResultsPreoperatively, there were 30 cases of stage 1 scapular dyskinesia and 28 cases of stage 2, with a scapular index measured at 53.84 (41.66–65.78), while the constant score was 41.46 (19–59). Upper trapezius pain was present in 87.7% of cases. The 57 patients were clinically assessed, with a mean follow-up of 8.9 months (6–24 months). Post-operatively, 15 cases (25.8%) of scapulalgia persisted at 2 months of follow-up, while upper trapezius pain was present in only 22.4%. Scapular dyskinesia was no longer present at 2 months in patients without scapulalgia. The scapular index was measured at 60.42 (52.38–70.96), and the constant score at last follow-up was 76.36 (42–92). ConclusionTenotomy of the pectoralis minor improves painful symptomatology and scapular dyskinesia, in cases of subacromial syndrome with retraction of the pectoralis minor muscle. Level of EvidenceIV, retrospective study.

Pilot study for treatment of symptomatic shoulder arthritis utilizing cooled radiofrequency ablation: a novel technique

To introduce cooled radiofrequency nerve ablation (C-RFA) as an alternative to managing symptomatically moderate to severe glenohumeral osteoarthritis (OA) in patients who have failed other conservative treatments and who are not surgical candidates or refuse surgery. This prospective pilot study includes a total of 12 patients experiencing chronic shoulder pain from moderate to severe glenohumeral OA. Patients underwent anesthetic blocks of the axillary, lateral pectoral, and suprascapular nerves to determine candidacy for C-RFA treatment. Adequate response after anesthetic block was over 50% immediate pain relief. Once patients were deemed candidates, they underwent C-RFA of the three nerves 2-3weeks later. Treatment response was evaluated using the clinically validated American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS) to assess pain, stiffness, and functional activities of daily living. Follow-up outcome scores were collected up to 6months after C-RFA procedure. Twelve patients underwent C-RFA procedure for shoulder OA. VAS scores significantly improved from 8.8 ± 0.6 to 2.2 ± 0.4 6months after the C-RFA treatment (p < 0.001). Patient's ASES score results significantly improved in total ASES from 17.2 ± 6.6 to 65.7 ± 5.9 (p < 0.0005). No major complications arose. No patients received re-treatment or underwent shoulder arthroplasty. Image-guided axillary, lateral pectoral, and suprascapular nerve C-RFA has minimal complications and is a promising alternative to treat chronic shoulder pain and stiffness from glenohumeral arthritis.

Multidirectional instability in female athletes.

Multidirectional instability (MDI) of the shoulder is characterized by generalized shoulder capsular laxity and symptomatic shoulder instability in more than one direction with one direction of instability as inferior. Generalized ligamentous laxity and specifically shoulder laxity, has been associated with female athletes. While males are at a higher risk of shoulder instability due to a number of extrinsic risk factors including participation in higher risk contact/collision activities, females are particularly susceptible to MDI due to their association with increased joint laxity. Patients with MDI often have a loose patulous capsule and display altered glenohumeral and scapulothoracic mechanics. The mainstay of treatment is physical therapy focusing on strengthening the dynamic stabilizers of the shoulder. In cases of failed rehabilitation, operative management most frequently includes either open or arthroscopic capsular shift with reasonably good outcomes and return to sport. Sex-related differences concerning shoulder instability risk and pathophysiology may influence treatment decisions and outcome measures. An understanding of the factors concerning shoulder instability specific to the female athlete is important in management and prevention of injury.

Ultrasound Features Associated With Shoulder Complaints: Calcifications Larger Than 6 mm in Young Patients and Positive Doppler Are Associated With Pain.

Objectives: To identify ultrasound (US) features associated with the presence of shoulder complaints.Methods: This observational, case-control study, compared US findings between participants with and without shoulder complaints, matched for age, sex, and dominancy. Data was collected from February 2018 to June 2020. Two-tailed Fisher's and Mann-Whitney U-tests were used, with p-values < 0.05 considered significant.Results: A total of 202 participants were enrolled (median age 56 years, range 18–70, 155 women), comprising 140 cases and 62 controls. A calcification size ≥6 mm, when age < 56 (p = 0.02), and a distance to tendon insertion ≥6 mm, when age ≥56 (p = 0.009), were only found in symptomatic shoulders. Color Doppler in rotator cuff (RC) tendons predominated in the presence of symptoms (26/140 vs. 2/62, p = 0.003). An algorithm also combining the number of calcifications, tendon echotexture and insertional thickening, osseous irregularity, cuff tears, and subacromial effusion showed a 92% (57/62) specificity for shoulder pain on this study sample.Conclusion: Calcification diameter of 6 mm or more is associated with shoulder pain in patients younger than 56 years. A distance from calcification to tendon insertion of 6 mm or more is related to pain in older patients. Doppler signal also is associated with shoulder pain. An algorithm based on a set of specific ultrasonographic criteria have a strong association with the presence of symptoms.

Shoulder adhesive capsulitis in cancer patients undergoing positron emission tomography - computed tomography and the association with shoulder pain.

BACKGROUNDAdhesive capsulitis is a relatively common condition that can develop in cancer patients during treatment. Positron emission tomography - computed tomography (PET-CT) is routinely performed as a follow-up study in cancer patients after therapy. Being aware of PET-CT findings to suggest shoulder adhesive capsulitis may help to alert clinicians for the diagnosis of unsuspected shoulder capsulitis.AIMTo assess the association of shoulder adhesive capsulitis with cancer/therapy type and symptoms in cancer patients undergoing PET-CT.METHODSOur prospective study received Institutional Review Board approval. Written informed consent was obtained from all patients, who answered a questionnaire regarding shoulder pain/stiffness at the time of PET-CT study, between March 2015 and April 2019. Patients with advanced glenohumeral arthrosis, metastatic disease or other mass in the shoulder, or shoulder arthroplasty were excluded. Patterns of shoulder capsule 18F-fluorodeoxyglucose (FDG) uptake were noted. Standard Uptake Value (SUV)max and SUVmean values were measured at rotator interval (RI) and deltoid muscle in bilateral shoulders. Normalized SUV (SUV of RI/SUV of deltoid muscle) was also calculated. We assessed if SUV values are different between symptomatic and asymptomatic patients in both shoulders. Covariates were age, gender, and therapy type (surgery, chemotherapy, radiation). Wilcoxon rank sum tests were used to compare unadjusted marginal differences for age, SUV measurements between symptomatic and asymptomatic patients. Multiple linear regression models were used to examine the relationship between right or left shoulder SUV measurements and symptom status, after adjusting for covariates. Statistical significance level was set at P < 0.05.RESULTSOf 252 patients initially enrolled for the study (mean age 66 years, 67 symptomatic), shoulder PET-CT data were obtained in 200 patients (52 were excluded due to exclusion criteria above). The most common cancer types were lymphoma (n = 61), lung (n = 54) and breast (n = 53). No significant difference was noted between symptomatic and asymptomatic patients in terms of age, gender, proportion of patients who had surgical therapy and radiation therapy. A proportion of patients who received chemotherapy was higher in patients who were asymptomatic in the right shoulder compared to those symptomatic in the right shoulder (65% vs 48%, P = 0.012). No such difference was seen for the left shoulder. In both shoulders, SUVmax and SUVmean were higher in symptomatic shoulders than asymptomatic shoulders (Left SUVmax 2.0 vs 1.6, SUVmean 1.6 vs 1.3, both P < 0.002; Right SUVmax 2.2 vs 1.8, SUVmean 1.8 vs 1.5, both P < 0.01). For lung cancer patients, bilateral RI SUVmax and SUVmean values were higher in symptomatic shoulders than asymptomatic shoulders. For other cancer patients, symptomatic patients had higher left RI SUVmax/mean than asymptomatic patients after adjustment.CONCLUSIONIn symptomatic patients metabolic activities in RI were higher than asymptomatic patients. Adhesive capsulitis should be considered in cancer patients with shoulder symptoms and positive FDG uptake in RI.

Arthroscopic Trillat procedure combined with capsuloplasty: an effective treatment modality for shoulder instability associated with hyperlaxity.

The aim of this study was to describe the results of an arthroscopic Trillat procedure utilized to treat patients with symptomatic antero-inferior shoulder instability associated with hyperlaxity. A retrospective review was performed on 19 consecutive shoulders (17 patients, 2 bilateral) who underwent a Trillat procedure combined with anterio-inferior capsulolabral plasty from 2016 to 2019. Patients included in the study presented with shoulder instability combined with shoulder hyperlaxity and no glenoid or humeral bone loss. Clinical assessment included range of motion, apprehension, and instability tests. Outcome measures Constant-Murley score (CMS) scale, Walch-Duplay, ROWE, Subjective Shoulder Value (SSV), Visual Analogue Scale (VAS). Post-operatively, healing of the coracoid osteoclasy was evaluated by CT scan. The mean follow-up was 24.8months (range, 12-51). Post-operatively, none of the patients experienced a recurrent dislocation or subluxation and the anterior apprehension test was negative in all shoulders. Post-operative motion deficits of 22.1° ± 15.8 [p < 0.05] and 12.4° ± 10.1 [p < 0.05] loss were documented for ER1 and ER2, respectively. All functional scores exhibited significant improvements. Post-operative CT scan was available in 16 shoulders and revealed coracoid union in 15/16 shoulders and an asymptomatic fibrous non-union without coracoid or implant migration in one patient. The arthroscopic Trillat procedure combined with an antero-inferior capsulolabral plasty is effective in preventing recurrent instability and eliminating shoulder apprehension among patients suffering from anterior and or inferior hyperlaxity. Level IV.

Arthroscopic Labral Repair Using Knotless Suture Anchors in the Setting of a 270° Labral Tear of the Shoulder

Extensive glenoid labral tears, whether the result of repetitive instability or first-time dislocation, compromise the mechanical stability of the glenohumeral joint due to disruption of the anterior, inferior, posterior, and/or superior portions of the labrum. These lesions often result in recurrent multiplanar instability and pain that is nonresponsive to conservative management and difficult to diagnose due to variability in clinical presentation and advanced imaging findings. Arthroscopic repair techniques to address symptomatic shoulder instability have showed positive patient-reported outcomes, low failure rates, and high return-to-sport rates. The evolution of knotless suture anchors offers a fixation method that has proven to be functionally equivalent to knotted suture anchors while avoiding the risks of knotted anchors (knot loosening, knot migration, articular abrasion) and allowing easier placement and decreased operative time. The purpose of this technique is to describe our preferred method to treat a 270° labral tear through arthroscopic knotless anchor repair and demonstrate the expanded application of this technique for extensive glenoid labral pathology.

Ultrasound of the symptomatic shoulder arthroplasty: Spectrum and prevalence of periarticular soft tissue pathology.

To describe our experience using ultrasound (US) to evaluate postoperative complications in the presence of in situ shoulder arthroplasty. Review of patients who underwent US evaluation following total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA) or hemiarthroplasty from 2007 to 2020. All studies were reviewed independently by two musculoskeletal radiologists to assess for joint effusion, periarticular collection, and characterization of associated rotator cuff tears. Tendon tears were assessed with respect to (1) thickness: low grade (<50% thickness), high grade (>50% thickness), full thickness; (2) morphology (focal vs. diffuse) and location (insertion vs. critical zone). Inter-reader agreements were determined using Cohen's kappa test. Ninety-seven studies were performed in 72 patients following TSA, RTSA, or hemiarthroplasty. Thirty-seven exams were solely for diagnostic purposes, and 59 were for guiding joint or periarticular collection aspiration. Twenty-eight studies assessed the cuff tendons post TSA. The mean time between surgery and US examination was 29.2 months. Complete or high-grade tears were identified in 8/28 (28.6%) diagnostic exams. The most commonly torn tendon among TSA patients was the subscapularis, with 13/28 (46.4%) demonstrating at least partial tearing. Inter-reader agreement was excellent for presence of effusion (k=0.79, p < .001) and periarticular collection (k=0.87, p < .001), and excellent agreement for presence of subscapularis tear (k=0.78, p < .001), with fair agreement for assessment of supraspinatus (k=0.66, p < .001) and infraspinatus (k=0.60, p < .001) tears. The most commonly torn tendon following anatomic TSA identified by US was the subscapularis, which was torn or deficient in 46.4% of cases. The majority of studies were performed for the guidance of percutaneous aspiration.

High Incidence of Anterior Shoulder Pain in Young Athletes Undergoing Arthroscopic Posterior Labral Repair for Posterior Shoulder Instability

PurposeThe purposes of this study were to determine the incidence of anterior shoulder pain in young athletes undergoing arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability and in patients with preoperative anterior shoulder pain treated without biceps tenodesis at the time of arthroscopic posterior labral repair who underwent a revision biceps tenodesis procedure at short-term follow up.MethodsA retrospective review was performed at a single institution over a 24-month period. The study included young patients who underwent an arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability. The electronic medical record, magnetic resonance arthrograms, and arthroscopic images were reviewed to exclude patients with posterior labral tears with anterior labral tear or SLAP (superior labrum anterior-to-posterior) tear extension on advanced imaging and arthroscopic examination. Data collected included the presence of preoperative tenderness to palpation of the biceps tendon in the groove, the results of a preoperative Speed test, postoperative Subjective Shoulder Value, the presence of postoperative anterior shoulder pain, and the need for a secondary biceps tenodesis.ResultsWe identified 65 patients who underwent arthroscopic labral repair for posterior shoulder instability. From this cohort, 26 patients with symptomatic unidirectional posterior shoulder instability underwent an arthroscopic posterior labral repair. The incidence of preoperative anterior shoulder pain with Zone 2 biceps groove tenderness and a positive Speed test was identified in 20 of 26 patients (76.9%). Of 26 patients, 5 (19%) had concomitant biceps tenodesis. The median postoperative Subjective Shoulder Value was 80 (interquartile range, 60-90) at median follow-up of 2.1 years. Of the 20 patients with preoperative anterior shoulder pain, 8 of 20 (40%) reported persistent anterior pain. One patient (4.7%) underwent a secondary biceps tenodesis.ConclusionsThere is a high incidence of anterior shoulder pain and Zone 2 biceps groove tenderness in patients undergoing isolated arthroscopic posterior labral repair for unidirectional posterior shoulder instability. At short-term follow-up, few patients required a secondary biceps tenodesis procedure; however, 30% of patients had persistent anterior shoulder pain.Level of EvidenceLevel IV, retrospective diagnostic case series.

Two-point discrimination and judgment of laterality in individuals with chronic unilateral non-traumatic shoulder pain

BackgroundCortical representation of the painful body region may be disrupted in several chronic pain conditions. The two-point discrimination test (TPDT) and the Left/Right Judgement Task (LRJT) have been used to identify changes in the cortical body schema in several chronic pain conditions. However, it is unclear if these changes are present for all chronic pain mechanisms. ObjectivesTo investigate the integrity of the body schema of the painful shoulder in patients with chronic unilateral nociceptive shoulder pain. MethodsThe sample consisted of 52 individuals with chronic unilateral nociceptive shoulder pain. The TPDT was measured over the anterosuperior and lateral regions of both shoulders using a staircase method. Participants also performed judgment tests of shoulder and foot laterality. The comparison of the TPDT and LRJT was performed using the linear regression model with mixed effects. ResultsThere was no difference in TPDT in the anterosuperior and lateral regions when comparing the symptomatic and asymptomatic shoulders. There was no difference in the LRJT accuracy and response time between the symptomatic and asymptomatic shoulders. No differences were observed when comparing LRJT variables from symptomatic shoulder and foot. ConclusionTherefore, results do not provide clear evidence of altered body schema in chronic nociceptive unilateral shoulder pain. This suggest that alterations in body representations may depend on the primary pain mechanism.

Safety and Systemic Exposure of Triamcinolone Acetonide Following Ultrasound-Guided Intra-Articular Injection of Triamcinolone Extended-Release or Standard Triamcinolone Acetonide in Patients with Shoulder Osteoarthritis: An Open-Label, Randomized Study.

Background and ObjectivesOsteoarthritis (OA) is a major public health burden. While knee and hip joints are most commonly affected, the glenohumoral (shoulder) joint is also frequently involved. We evaluated the pharmacokinetics and safety/tolerability of triamcinolone acetonide extended-release (TA-ER) and triamcinolone acetonide crystalline suspension (TAcs) in patients with shoulder OA.MethodsIn this phase 2, randomized, open-label, single-dose study (NCT03382262), adults with moderately-to-severely symptomatic shoulder OA for ≥ 6 months randomly received a single ultrasound-guided intra-articular (IA) injection of TA-ER 32 mg or TAcs 40 mg. Safety was evaluated throughout 12 weeks post-injection; blood samples for pharmacokinetic evaluations were collected pre-injection and through Day 85 post-injection.ResultsAmong 25 randomized patients, 12 received TA-ER and 13 received TAcs. Most patients were female (60%), and all had moderate (72%) or severe (28%) shoulder OA. Adverse events (AEs) were reported by four (33%) patients following TA-ER and three (23%) following TAcs injection. No AE was serious or led to study discontinuation. Systemic exposure following TAcs was approximately 1.5-fold higher than that following TA-ER injection (geometric mean [GM] AUC0–last 873,543 vs 557,602 h × pg/mL). GM Cmax was also higher in TAcs- than TA-ER-treated patients (2034 vs 1283 pg/mL). Bioequivalence testing confirmed lower systemic TA exposure following TA-ER than TAcs IA injection.ConclusionThese pharmacokinetic data confirm protracted release of TA from TA-ER following IA injection in patients with shoulder OA. Lower peak and systemic TA exposure following TA-ER suggests TA-ER could potentially confer an improved systemic safety profile over TAcs.Trial Registration NumberNCT03382262 (December 22, 2017 retrospectively registered).

Intra-Rater and Inter-Rater Reliability of Hand-Held Dynamometry for Shoulder Strength Assessment in Circus Arts Students.

Over two testing sessions, two experienced physiotherapists assessed the shoulder strength of 24 student circus artists with clinically diagnosed atraumatic shoulder instability. Both the symptomatic and asymptomatic shoulder was assessed using a HHD in 10 functional positions. Intra-class correlation coefficients (ICCs) were calculated to determine the reliability of strength measurements. All examined positions showed moderate-high intra-rater and inter-rater reliability. External rotation at 0° and internal rotation in horizontal flexion at 45° revealed the most reliable results, and the shrug position the least reliable. Inter-rater and intra-rater reliability was high and demonstrated similar results in symptomatic and asymptomatic shoulders by both raters. This study demonstrated clinical applicability in reliably measuring functional strength in symptomatic atraumatic instability or asymptomatic shoulders when assessed by experienced therapists using an HHD.