Symptomatic Shoulder Research Articles

Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty.

We sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises. We reviewed 151 patients with a mean age of 63.4 (range 40-90) years at a mean of 7.3 (range 2-19) years after this surgery. In 77 shoulders with previously unrepaired irreparable tears, simple shoulder test (SST) scores improved from an average of 4.6 (range 0-12) to 8.5 (range 1-12) (p<0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points. For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 (range 0-11) to 7.5 (range 0-12) (p<0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points. Smoothing of the humeroscapular interface can improve symptomatic shoulders with irreparable cuff tears and retained active elevation. This conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears. Level IV.

Multimodal assessment of sensorimotor shoulder function in patients with untreated anterior shoulder instability and asymptomatic handball players.

Functional evaluation of sensorimotor function of the shoulder joint is important for guidance of sports-specific training, prevention and rehabilitation of shoulder instability. Such assessment should be multimodal and comprise all qualities of sensorimotor shoulder function. This study evaluates feasibility of such multimodal assessment of glenohumeral sensorimotor function in patients with shoulder instability and handball players. Nine patients with untreated anterior instability of their dominant shoulder and 15 asymptomatic recreational handball players performed proprioceptive joint position sense and dynamic stabilization evaluations on an isokinetic device, as well as a functional throwing performance task. Outcome measures were analysed individually and equally weighted in a Shoulder-Specific Sensorimotor Index (S-SMI). Finally, isokinetic strength evaluations were conducted. We observed comparable sensorimotor functions of unstable dominant shoulders compared to healthy, contralateral shoulders (e.g. P=0.59 for S-SMI). Handball players demonstrated superior sensorimotor function of their dominant shoulders exhibiting a significantly higher throwing performance and S-SMI (P<0.001 and P=0.002, respectively), but comparable internal rotator peak torques for both shoulders (P>0.22). The present study proves feasibility of multimodal assessment of shoulder sensorimotor function in overhead athletes and patients with symptomatic anterior shoulder instability. Untreated shoulder instability led to a loss of dominance-related sensorimotor superiority indicating functional internal rotation deficiency. Dominant shoulders of handball players showed a superior overall sensorimotor function but weakness of dominant internal rotation constituting a risk factor for occurrence of posterior superior impingement syndrome. The S-SMI could serve as a diagnostic tool for guidance of sports-specific training, prevention and rehabilitation of shoulder instability.

Efficiency of quantitative echogenicity for investigating supraspinatus tendinopathy by the gray-level histogram of two ultrasound devices.

The gray-level histogram of ultrasound is a promising tool for scanning the hypoechogenic appearance of supraspinatus tendinopathy, and the aim of this study was to test the hypothesis that the gray-level value of the supraspinatus tendon in the painful shoulder has a lower value on B-mode images even though in different ultrasound devices. Sixty-seven patients who had unilateral shoulder pain with rotator cuff tendinopathy underwent bilateral shoulder ultrasonography, and we compared the mean gray-level values of painful shoulders and contralateral shoulders without any pain in each patient using two ultrasound devices. The echogenicity ratio (symptomatic/asymptomatic side) of two ultrasound devices was compared. A significant difference existed between the symptomatic shoulder and contralateral asymptomatic shoulder (p<0.001) on the mean gray-level value measurements of each device. The symptomatic-to-asymptomatic tendon echogenicity ratio of device A was 0.919±0.090 in the transverse plane and 0.937±0.081 in the longitudinal plane, and the echogenicity ratio of device B was 0.899±0.113 in the transverse plane and 0.940±0.113 in the longitudinal plane. The decline of the mean gray-level value and the echogenicity ratio of the supraspinatus tendon in the painful shoulder may be utilized as a useful sonographic reference of unilateral rotator cuff lesions. Diagnostic level III.

Imaging of postoperative shoulder instability

Postoperative imaging in shoulder instability is still a challenge for radiologists due to various postsurgical anatomical findings that could be considered pathologic in treated shoulder. For this reason is very important a deep knowledge about surgical procedures, anatomical changes after surgery and the appropriate diagnostic imaging modalities to work up the symptomatic postoperative shoulder. Postoperative imaging options include use conventional radiography, magnetic resonance imaging (MRI), MRI arthrography, computed tomography (CT) and CT arthrography. The purpose of our review is to explain the different surgical procedures and to describe postoperative changes detected with radiological imaging.

Clinically relevant magnetic resonance imaging (MRI) findings in elite swimmers’ shoulders

Background: Shoulder pain is the most common and well-documented site of musculoskeletal pain in elite swimmers. Structural abnormalities on magnetic resonance imaging (MRI) of elite swimmers’ symptomatic shoulders are common. Little has been documented about the association between MRI findings in the asymptomatic shoulder versus the symptomatic shoulder.Objective: To assess clinically relevant MRI findings in the shoulders of symptomatic and asymptomatic elite swimmers.Method: Twenty (aged 16–23 years) elite swimmers completed questionnaires on their swimming training, pain and shoulder function. MRI of both shoulders (n = 40) were performed and all swimmers were given a standardised clinical shoulder examination. Results: Both shoulders of 11 male and 9 female elite swimmers (n = 40) were examined. Eleven of the 40 shoulders were clinically symptomatic and 29 were asymptomatic. The most common clinical finding in both the symptomatic and asymptomatic shoulders was impingement during internal rotation, with impingement in 54.5% of the symptomatic shoulders and in 31.0% of the asymptomatic shoulders. The most common MRI findings in the symptomatic and asymptomatic shoulders were supraspinatus tendinosis (45.5% vs. 20.7%), subacromial subdeltoid fluid (45.5% vs. 34.5%), increased signal in the AC Joint (45.5% vs. 37.9%) and AC joint arthrosis (36.4% vs. 34.5%). Thirty-nine (97.5%) of the shoulders showed abnormal MRI features.Conclusion: MRI findings in the symptomatic and asymptomatic shoulders of young elite swimmers are similar and care should be taken when reporting shoulder MRIs in these athletes. Asymptomatic shoulders demonstrate manifold MRI abnormalities that may be radiologically significant but appear not to be clinically significant.

CSM 2017 Orthopaedic Section Platform Presentations (Abstracts OPL1–OPL64)

CSM 2017 Orthopaedic Section Platform Presentations (Abstracts OPL1–OPL64)

Latarjet procedure combined with inferior capsular shift for recurrent anterior shoulder instability in patients with hyperlaxity

Background Recurrent unidirectional anterior shoulder instability is a common disease especially among professional athletes. Open latarjet operation is a common surgical procedure used for the treatment of this condition, especially in cases associated with a high instability severity index score (ISIS) including cases with humeral bone loss (Hill–Sachs lesion) or anteroinferior glenoid bone loss. Persistent apprehension or recurrence of instability after the latarjet procedure might be attributed to associated anterior capsular laxity that was not addressed in the primary surgery. Hypothesis Combining coracoid bone transfer with capsulorraphy and capsular shift, and maintaining the sling effect of the conjoint tendon might be beneficial in patients with recurrent anterior shoulder instability associated with anterior capsular redundancy (ACR). Patients and methods A total of 30 patients with recurrent unilateral symptomatic involuntary unidirectional anterior shoulder instability were studied. All patients had an evidence of joint hyperlaxity with a Beighton score ranging from 6 to 9, mean 7.63±1.07. Evidence of ACR (Sulcus sign) was present. ISIS was superior than or equal to 4. In this study, the ISIS ranged from 6 to 10, with a mean of 8.38 and SD of 0.89. All of the patients underwent an open Latarjet procedure with superior capsular shift and capsulorraphy using Ethibond N:5 sutures wrapped around the serrations of the screw. All the patients were interrogated, examined clinically, and scored according to the Constant–Murley scoring system. Results The most important finding of this study is the marked improvement in the symptoms of instability as well as the level of function after surgery. There was a highly statistically significant difference between the preoperative and the postoperative Constant–Murley score. Conclusion In anterior shoulder instability with ACR, the Latarjet procedure associated with an anteroinferior capsulorrhaphy is an effective alternative to arthroscopic or open capsular shift and should help in reducing postoperative apprehension. The sooner the reconstructive surgery is performed, the better the functional outcome.

Shear Wave Ultrasound Elastographic Evaluation of the Rotator Cuff Tendon.

(1) Assess the association between the B-mode morphologic appearance and elasticity in the rotator cuff tendon using shear wave elastography (SWE). (2) Assess the association between SWE and symptoms. Institutional Review Board approval and informed consent were obtained. A retrospective review identified 21 studies in 19 eligible patients for whom SWE was performed during routine sonographic evaluations for shoulder pain. Evaluations were compared with 55 studies from 16 asymptomatic volunteers and 6 patients with asymptomatic contralateral shoulders. Repeated studies were accounted for by resampling. Proximal and distal tendon morphologic characteristics were graded from 1 to 4 (normal to full-thickness tear), and average shear wave velocity (SWV) measurements were obtained at both locations. In 68 examinations, deltoid muscle SWV measurements were available for post hoc analysis. The morphologic grade and SWV showed weak-to-moderate negative correlations in the proximal (P < .001) and distal (P = .002) rotator cuff tendon. A weakly significant SWV decrease was found in the proximal tendon in symptomatic patients (P = .049); no significant difference was seen in the distal tendon. The deltoid muscle SWV showed weak-to-moderate negative correlations with the morphologic grade in the proximal (P = .004) and distal (P = .007) tendon; the deltoid SWV was also significantly lower in symptomatic shoulders (P = .001). Shear wave elastography shows tendon softening in rotator cuff disease. It captures information not obtained by a morphologic evaluation alone; however, a poor correlation with symptoms suggests that SWE will be less useful in workups for shoulder pain than for preoperative assessments of tendon quality. Deltoid muscle softening seen in morphologically abnormal and symptomatic patients requires further exploration.

Surgical Release of the Pectoralis Minor Tendon for Scapular Dyskinesia and Shoulder Pain

Background: Pectoralis minor (PM) tightness has been linked to pain and dysfunction of the shoulder joint secondary to anterior tilt and internal rotation of the scapula, thus causing secondary impingement of the subacromial space. Purpose: To describe outcomes pertaining to nonoperative and operative treatment via surgical release of the PM tendon for pathologic PM tightness in an active population. Study Design: Case series; Level of evidence, 4. Methods: Over a 3-year period, a total of 46 patients were enrolled (mean age, 25.5 years; range, 18-33 years). Inclusion criteria consisted of symptomatic shoulder pain, limited range of overhead motion, inability to participate in overhead lifting activities, and examination findings consistent with scapular dysfunction secondary to a tight PM with tenderness to palpation of the PM tendon. All patients underwent a lengthy physical therapy and stretching program (mean, 11.4 months; range, 3-23 months), which was followed by serial examinations for resolution of symptoms and scapular tilt. Of the 46 patients, 6 (13%) were unable to adequately stretch the PM and underwent isolated mini-open PM release. Outcomes were assessed with scapula protraction measurements and pain scales as well as American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) scores. Results: Forty of the 46 patients (87%) resolved the tight PM and scapular-mediated symptoms with a dedicated therapy program (pre- and posttreatment mean outcome scores: 58 and 91 [ASES], 50 and 90 [SANE], 4.9 and 0.8 [VAS]; P < .01 for all), but 6 patients were considered nonresponders (mean score, 48 [ASES], 40 [SANE], 5.9 [VAS]) and elected to have surgical PM release, with improved scores in all domains (mean score, 89 [ASES], 90.4 [SANE], 0.9 [VAS]; P < .01) at final follow-up of 26 months (range, 25-30 months). Additionally, protraction of the scapula improved from 1.2 to 0.3 cm in a mean midline measurement from the chest wall preoperatively to postoperatively (P < .01), similar to results in nonoperative responders. No surgical complications were reported, and all patients returned to full activities. Conclusion: In most patients, PM tightness can be successfully treated with a nonoperative focused PM stretching program. However, in refractory and pathologically tight PM cases, this series demonstrates predictable return to function with notable improvement in shoulder symptoms after surgical release of the PM. Additional research is necessary to evaluate the long-term efficacy of isolated PM treatment.

Comparison of Glenoid Version and Posterior Humeral Subluxation in Patients With and Without Posterior Shoulder Instability

To evaluate glenoid version and humeral subluxation on preoperative multiplanar imaging of patients who underwent surgery for posterior glenohumeral instability compared with a matched group of patients who had shoulder surgery for other pathology. All patients over a 2-year period who underwent surgery for posterior instability had preoperative magnetic resonance (MR) imaging or MR arthrogram reviewed. Patients undergoing shoulder surgery for reasons other than instability were identified as a control group and matched by sex, laterality, and age. Measurement of glenoid version and percentage of humeral subluxation was performed by 2 reviewers after completing a tutorial. Reviewers were blinded to diagnosis and to whether or not the patients were in the experimental or control group. There were 41 patients in each group. The average glenoid version in the control group was 5.6° of retroversion (standard deviation [SD] 3.0), and the average humeral subluxation was 54% (SD 5.1%). In the experimental group, the average glenoid version was 8.1° of retroversion (SD 5.0). The average humeral subluxation in the experimental group was 56% (SD 6.8%). Student t test revealed a statistically significant difference in glenoid version (P=.009) but not humeral subluxation (P= .25). Intra- and inter-rater reliability was measured by the intraclass correlation coefficient and found to have an excellent Fleiss rating with regard to both measurements. Glenoid retroversion is significantly increased in patients with symptomatic posterior labral tears compared with a control group. However, there was no statistically significant difference between the groups with regard to posterior humeral subluxation and, therefore, is not a reliable indicator of the presence or absence of symptomatic posterior shoulder instability. Level III, retrospective comparative study.

Critical Findings on Magnetic Resonance Arthrograms in Posterior Shoulder Instability Compared With an Age-Matched Controlled Cohort

Background: Posterior shoulder instability is less common and potentially more difficult to diagnose clinically and radiographically compared with anterior shoulder instability. Radiographic findings including posterior labral tears, increased retroversion, presence of glenoid dysplasia, and increased capsular area are associated with symptomatic recurrent posterior shoulder instability. Purpose: This study aimed to determine the prevalence and severity of associated radiographic parameters found on magnetic resonance arthrograms (MRAs) in patients with arthroscopically confirmed isolated posterior labral tears and symptomatic recurrent posterior shoulder instability, compared with an age-matched cohort of patients without posterior instability or labral injury confirmed with shoulder arthroscopy. Study Design: Cross-sectional study, Level of evidence, 3. Methods: Patients who received a preoperative standard shoulder MRA at an academic institution over a 5-year period and had symptomatic posterior instability and received a repair of an arthroscopically confirmed posterior labral tear (n = 63) were identified. These patients were compared with an age-matched control group of patients without posterior instability (n = 49) who underwent an isolated arthroscopic distal clavicle resection that included an arthroscopic glenohumeral joint evaluation. Glenoid version, posterior humeral head subluxation, glenoid dysplasia, and linear and capsular area measurements were evaluated between the 2 groups. Interobserver reliability for continuous and categorical variables was assessed for all measurements. Results: Multivariate logistic regression revealed that the presence of increased glenoid retroversion (P = .0018), glenoid dysplasia (P = .03), and increased axial posterior capsular cross-sectional area (P = .05) were significantly associated with posterior labral tears and symptomatic posterior shoulder instability compared with the age-matched control group. Posterior humeral head subluxation was found to be a statistically significant variable with univariate analysis (P = .001) for posterior shoulder instability but not with multivariate logistic regression (P = .53). Interobserver reliability was good to very good for all measurements (intraclass correlation coefficient [ICC] = 0.74-0.85; κ = 0.64) but was moderate for total capsular area and sagittal capsular area measurements (ICC = 0.43-0.56). Conclusion: The presence of increased glenoid retroversion, glenoid dysplasia, and increased posterior capsular area on MRA are significantly associated with posterior labral tears and symptomatic posterior shoulder instability. Identification of these critical radiographic variables on magnetic resonance arthrography assists in the accurate diagnosis and management of clinically significant posterior shoulder instability.

Effects of dry needling to the symptomatic versus control shoulder in patients with unilateral subacromial pain syndrome

BackgroundInitial reports suggest that treating myofascial trigger points in the infraspinatus with dry needling may be effective in treating patients with shoulder pain. However, to date, high quality clinical trials and thorough knowledge of the physiologic mechanisms involved is lacking. ObjectivesTo examine the effect of dry needling to the infraspinatus muscle on muscle function, nociceptive sensitivity, and shoulder range of motion (ROM) in the symptomatic and asymptomatic shoulders of individuals with unilateral subacromial pain syndrome. DesignWithin-subjects controlled trial. MethodsFifty-seven volunteers with unilateral subacromial pain syndrome underwent one session of dry needling to bilateral infraspinatus muscles. Outcome assessments, including ultrasonic measures of infraspinatus muscle thickness, pressure algometry, shoulder internal rotation and horizontal adduction ROM, and questionnaires regarding pain and related disability were taken at baseline, immediately after dry needling, and 3–4 days later. ResultsParticipants experienced statistically significant and clinically relevant changes in all self-report measures. Pressure pain threshold and ROM significantly increased 3–4 days, but not immediately after dry needling only in the symptomatic shoulder [Pressure pain threshold: 5.1 (2.2, 8.0) N/cm2, internal rotation ROM: 9.6 (5.0, 14.1) degrees, horizontal adduction ROM: 5.9 (2.5, 9.4) degrees]. No significant changes occurred in resting or contracted infraspinatus muscle thickness in either shoulder. ConclusionsThis study found changes in shoulder ROM and pain sensitivity, but not in muscle function, after dry needling to the infraspinatus muscle in participants with unilateral subacromial pain syndrome. These changes generally occurred 3–4 days after dry needling and only in the symptomatic shoulders.

Three-dimensional scapular kinematics during open and closed kinetic chain movements in asymptomatic and symptomatic subjects

The combination of open kinetic chain (OKC) and closed kinetic chain (CKC) exercises is commonly recommended in shoulder rehabilitation, aiming at improving strength and sport-specific performance. This study aimed to investigate the three-dimensional (3-D) scapular kinematics and bilateral symmetry of scapular motion during dynamic OKC and CKC movements in asymptomatic and symptomatic shoulders. Fifty subjects with unilateral shoulder pain (symptomatic subjects diagnosed with subacromial impingement syndrome, n=20) or without shoulder pain during active shoulder elevation (asymptomatic subjects, n=30) participated in the study. Furthermore, 3-D scapular kinematics were recorded using an electromagnetic tracking device in the sagittal plane of shoulder elevation for both the OKC and CKC conditions performed with slings. Data for scapular kinematics and symmetry angle (SA) were analyzed at 30°, 45°, 60°, 90°, and 120° of humerothoracic elevation. Analysis of variance models and Student׳s t-test were used to make comparisons between conditions. In general, the scapula was more externally rotated, upwardly rotated and anteriorly tilted for asymptomatic shoulders, and more upwardly rotated for symptomatic shoulders during CKC shoulder elevation. Further, comparisons of SA obtained during OKC and CKC movements revealed that during CKC, scapular motion was more symmetrical for upward–downward rotation and anterior–posterior tilt in asymptomatic shoulders and for anterior–posterior tilt in symptomatic shoulders, especially above 90° humerothoracic elevation. Differences in scapular motion during the CKC condition were in a specific pattern and enhanced symmetry, which would be considered to be a position less likely to produce compression of the rotator cuff tendons for both training in asymptomatic populations and for treatment in early rehabilitation of patients, such as those who have shoulder impingement syndrome.

Glenoid Dysplasia

➤Subtle forms of glenoid dysplasia may be more common than previously thought and likely predispose some patients to symptomatic posterior shoulder instability. Severe glenoid dysplasia is a rare condition with characteristic radiographic findings involving the posteroinferior aspect of the glenoid that often remains asymptomatic.➤Instability symptoms related to glenoid dysplasia may develop over time with increased activities or trauma. Physical therapy focusing on rotator cuff strengthening and proprioceptive control should be the initial management.➤Magnetic resonance imaging and computed tomographic arthrograms are useful for detecting subtle glenoid dysplasia by revealing the presence of an abnormally thickened or hypertrophic posterior part of the labrum, increased capsular volume, glenoid retroversion, and posteroinferior glenoid deficiency.➤Open and arthroscopic labral repair and capsulorrhaphy procedures have been described for symptomatic posterior shoulder instability. Glenoid retroversion of >10° may be a risk factor for failure following soft-tissue-only procedures for symptomatic glenoid dysplasia.➤Osseous procedures are categorized as either glenoid reorientation (osteotomy) or glenoid augmentation (bone graft), and no predictable results have been demonstrated for any surgical strategy. Glenoid osteotomies have been described for increased retroversion, with successful results, although others have noted substantial complications and poor outcomes.➤In severe glenoid dysplasia, the combination of bone deficiency and retroversion makes glenoid osteotomy extremely challenging. Bone grafts placed in a lateralized position to create a blocking effect may increase the risk of the development of arthritis, while newer techniques that place the graft in a congruent position may decrease this risk.

Surgical Release of the Pectoralis Minor Tendon for Scapular Dyskinesia and Shoulder Pain

Pectoralis minor tightness has been linked to pain and dysfunction of the shoulder joint secondary to anterior tilt and internal rotation of the scapula causing pseudo-impingement of the subacromial space. The purpose of this study is to describe the outcomes pertaining to non-operative treatment and operative treatment via surgical release of the pectoralis minor tendon for pathologic pectoralis minor tightness in an active population. Over a 3-year period, a total of 46 patients were enrolled (mean age 25.5, range 18-33). Inclusion criteria: symptomatic shoulder pain, limited range of overhead motion, inability to perform overhead lifting activities, and scapular dysfunction secondary to a tight pectoralis minor with tenderness to palpation of the pectoralis minor tendon. All patients underwent a physical therapy and stretching program (mean 11.4 months, range 5-23), followed by serial examinations for resolution of symptoms and scapular tilt. 6/46 (13%) patients did not adequately recover and underwent isolated mini-open pectoralis minor release. Outcomes were assessed with scapula protraction measurements, pain scales, and ASES, SANE and VAS score. A total of 40/46 (87%) patients resolved the tight pectoralis minor and scapular mediated symptoms with non-operative treatment (ASES 58-91; SANE 50-90; VAS 4.9-0.8, p<0.01), but six patients were considered non-responders (mean ASES 48, SANE 40, VAS 5.9) and elected to have surgical pectoralis minor release, which improved scores in all domains (ASES 89; SANE 90.4; VAS 0.9, p<0.01). Additionally, protraction of the scapula improved from 1.2 to 0.3 cm in a mean midline measurement from the chest wall, preoperatively to postoperatively (p<0.01), similar to non-operative responders. All patients returned to full activities with no surgical complications. Although pectoralis minor tightness can be mostly treated non-operatively, this series demonstrates return to function with notable improvement in shoulder symptoms after surgical release of the pectoralis minor tendon.

Unusual Shoulder Pain Etiology in Old Man: Synovial Chondromatosis

Yaz›flma Adresi/Address for Correspondence: Fatih Bagcier MD, Ataturk University Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Erzurum, Turkey Tel.: +90 442 344 70 87 E-posta: bagcier_42@hotmail.com Gelis Tarihi/Received: 15.08.2015 Kabul Tarihi/Accepted: 01.09.2015 To the Editor; A 82-year-old male patient presented to our clinic with progressively worsening left shoulder pain. The pain started about 6 months ago, increased over time, spreading to the chest region. The characteristic of the pain was mechanical. He did not feel pain while sleeping. Previously, he had received analgesic medications but there was no significant improvement. There was no pain in any other joint, and there was no history of disease or trauma. Physical examination revealed the motion of the left shoulder joint was limited and painful in all directions. Neer’s impingement sign, Hawkins-Kennedy test, Yergasons tests were positive. There were no neurological deficits of the upper extremities. Serological and biochemical markers were normal. Impingement syndrome was diagnosed with physical examination. Magnetic resonance imaging (MRI) of the left shoulder revealed findings consistent with synovial chondromatosis (SC), which filled the subscapuler muscle region (Figure 1). Orthopedic surgical procedures including arthroscopic debridement were planned with symptomatic left shoulder. SC is a rare arthropathy of unknown etiology. The disease is generally monoarticular, usually occurs unilaterally in the large joints like the knee, hip, and elbow characterized by proliferation of the synovium with cartilaginous metaplasia (1). However any joint may be involved. Symptomatic presentation is quoted in the current literature mainly at the ages of 30 to 50 of a patient’s life. The diagnosis of SC is given after a thorough history, physical examination, and radiographic examination. Chronic, progressive pain, swelling, loss of motion and locking are more commonly seen symptoms, and soft-tissue swelling, crepitation, palpable loose bodies, and limited range of motion are the most common physical signs. It is beneficial to carry out computed tomography and MRI scans to identify and localize the lesions, and they also help to differentiate between other differential diagnoses. As radiotherapy and chemotherapy have no effect on SC, surgical removal of the affected synovium and the loose bodies is the preferred treatment (2). In the literature Kose et al. (3) presented a case with unilateral hip joint synovial osteochondromatosis, Giannetti et al. (4) presented a case with unilateral elbow joint synovial osteochondromatosis, Shearer et al. (5) presented a case with bilateral ankle joint synovial osteochondromatosis. Synovial osteochondromatosis was present in our case uncommon shoulder pain etiology in old man.

Are Pulley Exercises Initiated 6 Weeks After Rotator Cuff Repair a Safe and Effective Rehabilitative Treatment?

Background: There are few level 1 or 2 evidence studies that examine rehabilitation after rotator cuff repair. Pulleys have been used in postoperative shoulder rehabilitation with the intention of improving range of motion and developing strength. There is a concern that the use of pulleys in rehabilitation of rotator cuff repairs may contribute to excessive scapular motion (scapular substitution) and potentially inferior outcomes. Hypothesis: Rotator cuff repair patients treated with pulley exercises would have increased scapular substitution and inferior patient-determined outcome scores, range of motion, and strength compared with patients treated with an alternative rehabilitation program without pulleys. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 27 patients who underwent rotator cuff repair were randomized to a rehabilitation group that used pulleys initiated 6 weeks postoperatively, and 26 patients followed a rehabilitation protocol without pulleys. Inclusion criteria were patients undergoing arthroscopic rotator cuff repair. Exclusion criteria were large to massive rotator cuff tears, revision rotator cuff repair, glenohumeral osteoarthritis, adhesive capsulitis, and a symptomatic contralateral shoulder. Outcomes of intervention were patient-determined outcome scores (Western Ontario Rotator Cuff Index [WORC], American Shoulder and Elbow Surgeons [ASES] Shoulder Score, Single Assessment Numeric Evaluation [SANE], Shoulder Activity Level, and Simple Shoulder Test [SST]), range of motion, scapular substitution, and strength. Outcomes were determined at 6, 12, 18, 26, and 52 weeks. A power analysis determined that 22 patients were needed per group to have a power of 0.80, α = 0.05, and effect size of f = 0.5. Results: Both groups had statistically significant improvements in WORC, ASES Shoulder Score, SST, and SANE scores over time after rotator cuff repair (P < .0001). There were no differences between the interventions for WORC (P = .18), ASES Shoulder Score (P = .73), SANE (P = .5), Shoulder Activity Level (P = .39), or SST (P = .36). Both interventions demonstrated improvements in shoulder flexion (P = .002), abduction (P = .0001), external rotation (P = .02), strength (P ≤ .0002), and scapular substitution (P ≤ .07) over time after rotator cuff repair. However, there was no difference in range of motion (P ≥ .26), strength (P ≥ .20), or scapular substitution (P ≥ .17) between interventions. Conclusion: A rotator cuff repair rehabilitation program that uses pulleys does not result in inferior outcomes, as determined by patient-determined outcome scores, measurements of scapular substitution, range of motion, and scaption strength. Registration: ClinicalTrials.gov NCT01819909

Reliability, agreement, and diagnostic accuracy of the Modified Lateral Scapular Slide test

BackgroundThe Lateral Scapular Slide Test is a static test used in clinical settings to assess medio-lateral inferior angle displacement and scapular asymmetry at three different degrees of shoulder abduction. However, there is no evidence in the literature about the reliability and diagnostic accuracy of a modified LSST (arm elevation in the scapular plane with loading) in a symptomatic population. ObjectiveTo assess the intra- and inter-rater reliability, agreement, and diagnostic accuracy of the MLSST ​ (Modified Lateral Scapular Slide Test) in subjects with and without shoulder symptoms. A new test position is examined, in which the arm is held in 90° of elevation in the scapular plane with 1 kg load. DesignWithin day intra- and inter-rater reliability, agreement, and diagnostic accuracy study. MethodParticipants included 25 (42 ± 2.7 years) subjects with shoulder symptoms and 25 (40 ± 2.1 years) asymptomatic control subjects. Two raters, blinded to each other's outcomes, measured the distance between the inferior scapular angle and T7 at arms by the side, hands on hips and 90° of arm elevation in the scapular plane with 1 kg load. Measurements were performed twice, bilaterally. Intraclass correlation coefficient (ICC), minimal detectable change (MDC95%) and diagnostic accuracy were calculated. ResultsThe ICCs for intra- and inter-rater reliability were good to high in both shoulders of symptomatic and asymptomatic groups. The MDC95% in the symptomatic group ranged between 0.67 and 1.40 cm in the symptomatic shoulder and 0.72–1.16 cm in the asymptomatic shoulder. The asymptomatic group presented a MDC95% ranging between 0.63 and 1.52 cm in the dominant and 0.60–1.41 cm in the non dominant shoulder. Positive and negative likelihood ratios ranged between 0.67–5.50 and 0.81–1.11, respectively. ConclusionThe MLSST had good reliability and agreement properties to assess scapular position in both groups. However, no test position had clinical utility as a diagnostic criterion for shoulder pathology.

Reverse total shoulder arthroplasty in wheelchair-dependent patients

Wheelchair-dependent patients have a high incidence of shoulder pathology, often causing severe impairment. This study reports outcomes of wheelchair-dependent lower extremity-impaired patients with symptomatic shoulder arthritis or severe rotator cuff pathology treated with reverse total shoulder arthroplasty (RTSA). Data for 19 wheelchair-dependent patients who had an RTSA for symptomatic arthritis or rotator cuff pathology, or both, were obtained from the University of Florida Shoulder Arthroplasty Database. Included were 16 of 19 shoulders with adequate follow-up averaging 40 months. Functional outcome scores included the Simple Shoulder Test, University of California Los Angeles Shoulder Rating Scale, Shoulder Pain and Disability Index, American Shoulder and Elbow Surgeons score, Constant score, and 12-item Short Form (SF-12) health survey. Objective measures were active elevation, external rotation, and internal rotation. Radiographs were evaluated for lucent lines, notching, and prosthetic loosening. All measured parameters, except the SF-12, significantly improved at the final follow-up. Functional outcome scores included Shoulder Pain and Disability Index, 45; Simple Shoulder Test, 7; American Shoulder and Elbow Surgeons, 73; University of California Los Angeles Shoulder Rating Scale, 30; Constant, 70; and SF-12, 33. Active elevation was 112°, and active external rotation was 29°. Most patients (83%) were satisfied. The complication rate was 25%; baseplate failure and dislocation occurred early, and periprosthetic humeral fracture secondary to infection occurred late. The notching rate was 42%. Shoulder pain and dysfunction due to arthritis and rotator cuff pathology can result in the loss of independence in wheelchair-dependent patients. We investigated whether RTSA can sustain the increased loads placed by these patients during transfers. Wheelchair-dependent patients can benefit from an RTSA for shoulder pain and dysfunction but must accept worsened impairment during the immediate postoperative period and a higher complication rate than the general population treated with an RTSA.

Reliability of ultrasound evaluation of the long head of the biceps tendon.

To determine the reliability of quantitative measures of the long head of the biceps tendon using an ultrasound-imaging system. Intra- and inter-rater reliability study. Thirty-one participants without shoulder pain. All participants took part in 3 ultrasound imaging sessions; they were assessed by 2 evaluators (inter-rater reliability), one of whom assessed them twice (intra-rater reliability). All measurements were taken at the widest identified part of the tendon using longitudinal and transverse views. Measurements of the long head of the biceps tendon included width, thickness and cross-sectional area. Intraclass correlation coefficients and minimal detectable change were used to characterize reliability. Intra- and inter-rater reliabilities were excellent for all measures when the mean of 2 measures were considered, except for inter-rater reliability of the width, for which it ranged from 0.76 to 0.86. Minimal detectable change ranged from 0.3 to 1.6 mm for width and thickness, and from 2.8 to 4.9 mm2 for cross-sectional area. Ultrasound measurement of the long head of the biceps tendon is a highly reliable method, except for the width. When measuring the long head of the biceps tendon, a mean of 2 measurements is recommended. Now that reliability has been shown in healthy individuals, the next step will be to determine the validity/reliability of these quantitative measures in symptomatic shoulders.