Symptomatic Shoulder Research Articles

Reliability and Validity of the Measurement of Scapular Position Using the Protractor Method.

The protractor method is a proposed clinical assessment tool, the first to measure vertical scapular position, that directly compares scapular and spinal landmarks. This tool has the potential to reliably and accurately measure excessive scapular elevation or depression. The purpose of this study was to determine reliability and validity of the protractor method to measure resting scapular position. An interrater and intratester reliability and validity study was conducted. Testing was conducted on the same day by 2 physical therapists who were blinded to each other's results. The vertical distances between the spinous process of C7 and the superior margin of the medial aspect of the spine of the scapula (C7 method) and the spinous process of T8 and the inferior angle of the scapula (T8 method) were palpated and measured on the symptomatic shoulder in 34 people with current shoulder pain using the protractor method. Measurements were compared with 2-dimensional camera analysis to assess validity. For intertester reliability, the standard error of measure, minimal detectable change, and intraclass correlation coefficient were 6.3 mm, 17.3 mm, and .78, respectively, for the C7 method and 5.7 mm, 15.7 mm, and .82, respectively, for the T8 method. For intratester reliability, the standard error of measure, minimal detectable change, and intraclass correlation coefficient were <0.9 mm, <2.5 mm, and .99, respectively. For validity, significant correlations (r) and mean differences were .83 and 10.1 mm, respectively, for the C7 method and .92 and 2.2 mm, respectively, for the T8 method. The results of this study are limited to static measurement of the scapula in one plane. Both protractor methods were shown to have good reliability and acceptable validity, with the T8 method demonstrating superior clinical utility. The clinical use of the T8 method is recommended for measurement of excessive resting scapular elevation or depression.

Stretching program dedicated to shoulder stiffness: Functional consequences

Overhead athletes develop a specific pattern of glenohumeral passive mobility, with external rotator gain (ERG) and internal rotation deficit (GIRD). The GIRD should correspond to tightness of the posterior structure and it seemed to be linked to various dominant shoulder pathologies. Twenty men overhead athletes were recruited from handball and volleyball clubs. To be eligible, participants had to be involved at least 6 hours in practice since at least 5 years. Ten men (22.5 ± 4 years) were asymptomatic, 10 men (24.8 ± 4 years) were symptomatic on their dominant shoulder (at least 3/10 on the VAS). They all should present, on their dominant shoulder, a GIRD based on a clinical assessment. The subjects performed daily two kinds of stretching at the dominant side for 4 weeks (5 × 30″): the sleeper stretch and the cross body arm. They sustained, before and after the stretching program, an isokinetic evaluation of the external and internal rotators and an evaluation of the scapula kinematics (3D assessment). After the stretching program, all the subjects showed a significant decrease of the shoulder stiffness. We did not observe any alteration of scapular kinematics among the asymptomatic athletes after 4 weeks of stretching. Concerning the symptomatic athletes, the stretching program modified the position at rest of the scapula, which was less anteriorly tilted after the program. During the isokinetic evaluation, only the asymptomatic population showed a low (–4%; P < 0.05) decrease of the internal rotators maximal strength at 60°/s in the concentric mode. The symptomatic overhead athletes reported a significant reduction of shoulder pain; the decrease of pain was significantly correlated with the increase of passive internal rotation of the dominant shoulder. The stretching program devoted, during 4 weeks, to the stiffness shoulder allowed an increase in passive rotation. This gain in mobility was correlated with a significant reduction of pain in symptomatic shoulder.

Elasticity of the Coracohumeral Ligament in Patients with Adhesive Capsulitis of the Shoulder.

To evaluate the elasticity of the coracohumeral ligament (CHL) in healthy individuals and patients with clinical findings suggestive of unilaterally involved adhesive capsulitis of the shoulder (ACS). The institutional review board approved this single-institution prospective study, which was performed between November 15, 2012, and July 8, 2014. Informed consent was obtained from all subjects. Measurement of CHL thickness was performed in the axial oblique plane under shoulder maximal external rotation. Shear-wave elastography (SWE) was used to evaluate elasticity of the CHL in healthy individuals (11 men, 19 women aged 22-62 years) and those with clinical findings suggestive of ACS (nine men, 11 women aged 41-70 years). SWE was performed in the shoulder-neutral position and under maximal external rotation. The Wilcoxon signed-rank test was performed to compare the thickness and elastic modulus of the CHL between bilateral shoulders. In all subjects, the CHL elastic modulus was larger under maximal external rotation than in the neutral position (P < .001 for all). For healthy subjects, there was no significant difference in the CHL elastic modulus between the dominant and nondominant shoulders. For patients presumed to have ACS, the CHL thickness was significantly greater in the symptomatic shoulder than in the unaffected shoulder (P < .001). The CHL elastic modulus of the symptomatic shoulder (median, 234.8 kPa; interquartile range [IQR], 174.4-256.7 kPa) was significantly greater than that of the unaffected shoulder (median, 203.3 kPa; IQR, 144.1-242.7 kPa) in the shoulder-neutral position (P = .004) but not under maximal external rotation (P = .123). When bilateral shoulders were maintained at the same angle of external rotation, the CHL elastic modulus was greater in the symptomatic shoulder than in the unaffected shoulder (P = .005). In patients with clinical findings suggestive of ACS, SWE showed that the CHL is stiffer in the symptomatic shoulder than in the unaffected shoulder.

Calcific tendinopathy of the rotator cuff: the correlation between pain and imaging features in symptomatic and asymptomatic female shoulders.

To provide new epidemiological data regarding the prevalence, distribution and macroscopic features of shoulder rotator cuff calcific tendinopathy (calcific tendinopathy), and to identify the characteristics of calcific deposits associated with shoulder pain. Three hundred and two female volunteers (604 shoulders) who had been referred to a gynaecological clinic participated in the study. The subjects underwent a high-resolution ultrasonography of both shoulders, and those with a diagnosis of calcific tendinopathy compiled a standardized questionnaire relating to shoulder symptoms. We determined the prevalence of symptomatic and asymptomatic rotator cuff calcific tendinopathy, and compared differences in distribution and macroscopic features of the symptomatic and asymptomatic calcifications. The prevalence of calcific tendinopathy was 17.8% (103 shoulders). Ninety-five shoulders (15.7%) were symptomatic; of these, calcific tendinopathy was found in 34 shoulders (33%) on imaging. Of the 509 asymptomatic (84.3%) shoulders, calcific tendinopathy was observed in 69 cases (67%). Among tendons, supraspinatus (53.4%) and infraspinatus (54.6%) were the most frequently involved. The majority of calcific deposits were of maximum diameter between 2 and 5 mm (77.9%), and were linear in form (69.9%). The involvement of multiple tendons and a location in the supraspinatus tendon were found to be significantly correlated with pain (p = 0.023, p = 0.043 respectively), as were age (p = 0.041) and an excessive body mass index (p = 0.024). In this sample from the general population of working age females, both intrinsic factors (location in supraspinatus, multiple tendon involvement) and extrinsic variables (age, abnormally high BMI) were correlated with pain in calcific tendinopathy. Level III, cross-sectional study, prevalence study.

Glenohumeral Joint Pain Referral Patterns: A Descriptive Study.

Pain diagrams are a useful tool to help physicians understand the varying presentation patterns of specific pain generators. This study is the first to describe the potential pain patterns of the glenohumeral joint (GHJ) based on responses to diagnostic image-guided GHJ injections. To determine potential GHJ pain referral patterns. 162 consecutive patients undergoing 168 GHJ injections recorded their preprocedure pain scores and drew accurate pain diagrams prior to undergoing fluoroscopically guided GHJ injections with local anesthetic. Postprocedure pain scores were recorded and those with complete relief were considered responders. Pain diagrams were overlaid via computer software to facilitate analysis and a composite pain map. A responder composite was also compared with a nonresponder composite. The GHJ was shown to cause pain in traditionally localized areas of the anterior and/or posterior shoulder and upper arm regions in 100% of patients who experienced complete pain relief after injection. Among 100% responders, 18% had neck pain and 6% had scapular pain. Pain was shown to radiate distally, with anterior forearm pain in 9%, posterior forearm pain in 8%, and hand pain in 9%. No patients with pain both in the medial neck and below the elbow were found to be 100% responders. Similarly, no patients were 100% responders if they had pain in the medial scapula and below the elbow, or medial scapula and medial neck. Anterior or posterior shoulder and upper arm pain, or a combination of the two, is the most common pain referral area from a symptomatic shoulder joint. Referral to the lateral neck, in combination with shoulder pain, was occasionally seen. Pain referral to the forearm and hand was less common. Rarely did a symptomatic shoulder joint refer pain to the scapula or to the medial neck.

In vivo 3-dimensional analysis of scapular and glenohumeral kinematics: comparison of symptomatic or asymptomatic shoulders with rotator cuff tears and healthy shoulders

Alteration in shoulder kinematics has been suggested as one cause of symptoms in shoulders with rotator cuff tears (RCTs). However, only a few studies comparing symptomatic and asymptomatic RCTs using kinematic analysis have been performed. The purpose of this study was to compare 3-dimensional (3D) scapular and glenohumeral kinematics during scapular-plane abduction among symptomatic RCTs, asymptomatic RCTs, and healthy shoulders. This study included 7 healthy shoulders in subjects with a mean age of 62 years, 5 symptomatic RCTs in subjects with a mean age of 70 years, and 7 asymptomatic RCTs in subjects with a mean age of 67 years. All shoulders with RCTs had medium-sized tears (1-3 cm in the coronal plane) that were confirmed with magnetic resonance imaging. Biplane fluoroscopic images during scapular-plane abduction were recorded, and computed tomography-derived 3D bone models were matched with the silhouettes of the bones on the fluoroscopic images using 3D/2-dimensional model-image registration techniques. Angular values of the scapula and glenohumeral kinematics were compared among the 3 groups. Posterior tilt of the scapula was significantly smaller in the symptomatic RCTs (3.1° ± 1.8°) than in healthy shoulders (10.4° ± 0.8°) (P = .049). The humerus of the symptomatic shoulders was less externally rotated relative to the scapula throughout the activity than the healthy shoulders and asymptomatic RCTs (P = .006 and P = .028 respectively). However, there were no kinematic differences between the asymptomatic RCTs and healthy shoulders. Kinematic changes in symptomatic RCTs might be associated with development of symptoms. Improvement of these kinematic changes may be a key to successful conservative treatment for symptomatic RCTs.

A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: a randomised controlled trial (the SELF study)

Objectives: To evaluate the clinical effectiveness of a self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy. Design: Multi-centre pragmatic unblinded parallel group randomised controlled trial. Setting: UK National Health Service. Participants: Patients with a clinical diagnosis of rotator cuff tendinopathy. Interventions: The intervention was a programme of self-managed exercise prescribed by a physiotherapist in relation to the most symptomatic shoulder movement. The control group received usual physiotherapy treatment. Main outcome measures: The primary outcome measure was the Shoulder Pain & Disability Index (SPADI) at three months. Secondary outcomes included the SPADI at six and twelve months. Results: A total of 86 patients (self-managed loaded exercise n=42; usual physiotherapy n=44) were randomised. Twenty-six patients were excluded from the analysis because of lack of primary outcome data at the 3 months follow-up, leaving 60 (n=27; n=33) patients for intention to treat analysis. For the primary outcome, the mean SPADI score at three months was 32.4 (SD 20.2) for the self-managed group, and 30.7 (SD 19.7) for the usual physiotherapy treatment group; mean difference adjusted for baseline score: 3.2 (95% Confidence interval -6.0 to +12.4 P = 0.49). By six and twelve months there remained no significant difference between the groups. Conclusions: This study does not provide sufficient evidence of superiority of one intervention over the other in the short-, mid- or long-term and hence a self-management programme based around a single exercise appears comparable to usual physiotherapy treatment.

Physiotherapy treatment for atraumatic recurrent shoulder instability: early results of a specific exercise protocol using pathology-specific outcome measures.

Recurrent shoulder instability is usually caused by a traumatic event resulting in structural pathology, although a small subgroup of patients experience symptomatic recurrent shoulder instability without trauma. These patients are usually treated non-operatively but limited evidence exists regarding effective conservative management. In particular, there is a lack of reproducible exercise regimes and none that have been tested with condition-specific outcome measures. A service evaluation was conducted over a 15-month period to assess our current treatment protocol used in the management of patients with atraumatic recurrent shoulder instability. The regime is reproducible with target-led progression milestones. Oxford Instability Shoulder Scores (OISS) and Western Ontario Shoulder Index (WOSI) scores were compared between baseline and final follow-up. Eighteen consecutive patients were included with mean follow-up of 4.5 months (range 1.35 months to 11.77 months). A statistically significant improvement was seen in both outcome measures. Mean OISS improved by 16.67 points (confidence interval: 12.34 to 20.99; p < 0.001). Mean WOSI improved by 36.76% (confidence interval: 28.46 to 45.06; p < 0.001). For this small group of patients with recurrent atraumatic shoulder instability, the Derby Shoulder Instability Programme produced significant improvements over the short term, with a high level of patient compliance. This is the first study to include pathology-specific patient-reported outcome measures to assess outcomes from a specific and reproducible exercise regime in this group of patients. The findings support further research to evaluate the exercise protocol in a larger group of patients over the longer term.

Effectiveness of the eccentric exercise therapy in physically active adults with symptomatic shoulder impingement or lateral epicondylar tendinopathy: A systematic review.

To identify and criticize the evidence for the effectiveness of the eccentric exercise to treat upper limb tendinopathies. Systematic review. Relevant randomized controlled trials (RCTs) were sourced using MEDLINE, SPORT Discus, Physiotherapy Evidence Database (PEDro) and CINAHL databases. Inclusion criteria were: (1) studies in English or Spanish; (2) adult participants with clinical diagnosis of tendinopathy; (3) RCT study design; (4) results regarding pain or strength were assessed; and (5) eccentric exercise was employed to treat upper extremity tendinopathies. Two blinded reviewers independently extracted data concerning trial methods, quality and outcomes. PEDro scale was employed to assess methodological quality. Results were summarized in a best evidence synthesis. The selected studies (n=12) scored an average of 6/10 based on the PEDro score. In 11 studies, pain decreased significantly with eccentric exercise, but only in five studies, the reduction was significantly better than in the non-eccentric group (in all or some of the parameters). Strength was assessed in nine studies; within-group evaluations show that strength significantly improved in the eccentric-group in seven studies, whereas inter-group changes were only significantly better in the eccentric-group in three studies for all the parameters and in two studies for some of the parameters. Eccentric exercise may reduce pain and improve strength in upper limb tendinopathies, but whether its effectiveness is much better than other forms of treatment remains questionable. Further investigations are needed, not only focused on shoulder impingement or epicondylar tendinopathy, but on tendinopathies in other areas of the upper limb.

Arthroscopic Stabilization of Posterior Shoulder Instability Is Successful in American Football Players

To evaluate subjective and objective clinical outcomes of arthroscopic posterior capsulolabral repair for the treatment of symptomatic unidirectional posterior shoulder instability in American football players. Fifty-six consecutive American football players with unidirectional posterior shoulder instability underwent an arthroscopic posterior capsulolabral repair with or without suture anchors. Patients were evaluated, with return to play as the primary outcome measure supplemented with the American Shoulder and Elbow Surgeons (ASES) scoring system. Stability, range of motion, strength, pain, and function were also assessed with subjective scales. At a mean follow-up of 44.7 months postoperatively, 93% returned to sport and 79% returned to sport at the same level. Significant improvements (P < .01) were seen between preoperative and postoperative evaluations in ASESscore and subjective scores of stability, range of motion, strength, pain, and function. Excellent or good results (ASES score > 60; stability < 6) were achieved in 96.5% of athletes, and 96% were satisfied with their operations. Arthroscopic capsulolabral repair for unidirectional posterior shoulder instability is effective in American football players because it improves stability, pain, and joint function, which optimizes the likelihood of successful return to play. Case series; Level of evidence, IV.

Prevalence of and Risk Factors for Dislocation Arthropathy

Background: Glenohumeral osteoarthritis is a well-documented, long-term complication of open stabilization procedures. However, there is a lack of knowledge about long-term radiographic outcome after arthroscopic Bankart procedures. Hypothesis: Glenohumeral osteoarthritis will develop less frequently in arthroscopic Bankart repair compared with open repairs reported in the literature. Study Design: Case series; Level of evidence, 4. Methods: The inclusion criteria for this study were (1) all-arthroscopic Bankart repair for a (2) symptomatic anteroinferior shoulder instability and (3) a minimum follow-up of 10 years. True anteroposterior and lateral radiographs were obtained to evaluate the prevalence and grade of osteoarthritis according to the Samilson classification. Patients were assessed by the Constant score and examined for passive external rotation deficits. Results: Of 165 shoulders that fulfilled the inclusion criteria, 100 were available for evaluation. The median Constant score at an average ± SD 156.2 ± 18.5 months after Bankart repair was 94 (range, 46-100). Twenty-one shoulders (21%) sustained a recurrent dislocation. Overall, 31% of shoulders showed no evidence of glenohumeral osteoarthritis; 41% showed mild, 16% moderate, and 12% severe degenerative changes. Osteoarthritis did not correlate with Constant score results (P = .427). The grade of osteoarthritis was significantly associated with the number of preoperative dislocations (P = .016), age at initial dislocation (P = .005) and at surgery (P = .002), and the number of anchors used (P = .001), whereas time from initial dislocation to surgery (P = .854) and external rotation deficit at 0° and 90° of abduction (P = .104 and .348, respectively) showed no significant correlation. Recurrent dislocation did not affect the presence or grade of osteoarthritis (P = .796 and .665, respectively). Conclusion: At an average 13 years after arthroscopic Bankart repair, osteoarthritic changes are a common finding and, overall, are comparable with reports in the literature regarding open procedures as well as nonoperative treatment. The extent of trauma sustained during preoperative dislocations and the age of the patient seem to be more relevant for long-term dislocation arthropathy than the kind of treatment. Accordingly, the study hypothesis must be rejected. Avoiding preoperative dislocations is more important for the prevention of osteoarthritis than short-term treatment. The number of anchors used was found to be a predictor for long-term development of osteoarthritis.

What Is the Accuracy of Shoulder Range of Motion Measurements on Physical Exam?

The purpose of this study is to investigate a new method for measuring shoulder range of motion (ROM) in an orthopedic practice utilizing a smartphone application to improve accuracy from physical exam typically used in research. Our aim is to evaluate the application, Physio2Go (P2G), which uses a virtual goniometer, assessing validity by comparing its measurements to those taken by a universal goniometer (UG). Two observers of varying clinical experience, a research assistant and research fellow, compared measurements. Statistically, we used the intra-class correlation coefficient (ICC), standard error of measurement (SEM), and the Pearson correlation coefficient (PCC). Following validation we tested P2G in symptomatic postoperative shoulder patients measuring forward flexion (FF) and external rotation (ER). We compared P2G measurements to visual estimation (VE) done by a fellowship trained orthopedic surgeon. Statistically we used ICC, Bland- Altman plots with 95% limits of agreement (LOA), and scatter plots. We examined the impact of the application using Welch’s t-test comparing pre-to-postoperative ROM improvements using the values obtained by P2G and VE. We found high intra-rater reliability of P2G for both observers, substantial correlation between UG and P2G measurements, highly correlated inter-observer reliability for UG and P2G, and statistically significant PCC values (p < 0.05). As expected, ROM measurements of symptomatic patients comparing P2G and VE measurements demonstrated lower correlation. Bland-Altman plots demonstrated wide confidence intervals; scatterplots and histograms confirmed low agreement among measurement methods. Clinical application demonstrated varying statistical significance depending on whether measurements were done by P2G or VE. Our study found that P2G provided superior reliability compared to the customary physical exam routinely used for orthopedic research. The value of using this application instead of a UG is the ease of use and the ability for any member of the healthcare team, regardless of clinical experience to be able to produce reliable and valid measurements.

Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults.

The aim of this study was to determine the prevalence of structural shoulder pathology using magnetic resonance imaging (MRI) in three groups of older people: those with current shoulder pain, those with a previous history of shoulder pain and those with no history of shoulder pain, within a community-based sample. Thirty subjects (10 within each of the three groups) participated in the study. Subjects were recruited by telephone and underwent a clinical examination of shoulder and neck range of movement (to ensure pain was not referred from the neck). Subjects completed the Shoulder Pain and Disability Index (SPADI) and underwent MRI and X-ray of the relevant shoulder. The X-rays and MRI were read independently by two experienced musculoskeletal radiologists blinded to each participant's symptoms. The MRIs were read using a structured reporting system. The mean range of shoulder movement on both the right and left sides was lower for the current pain group compared to both the no and previous pain groups. On X-ray, there was no significant difference between groups in terms of glenohumeral and/or acromioclavicular degenerative changes. Tendinosis and tears of the rotator cuff were present in the majority of participants in each group. Labral abnormalities were rare among all groups. Shoulder pathology is apparent in both symptomatic and asymptomatic shoulders and clinical symptoms may not match radiological findings. The cost burden of ordering MRI scans is significant and the relevance of the findings are questionable when investigating shoulder pain.

Shoulder Symptoms and Function in Geriatric Patients

Musculoskeletal problems, including shoulder pain, are common in the general population and are often cited as reasons for physician visits. Although many risk factors for shoulder pain are postulated, the effects of shoulder pain on functional level and perceived quality of life are poorly characterized in older adults. In this study, we set out to determine the prevalence and impact of shoulder symptoms and dysfunction in an older adult veteran population. A chart review, cross-sectional survey, and examination were performed. A sample of 93 individuals, aged 60 years or older, was recruited from a primary clinic outpatient waiting room at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin. Patients were asked about shoulder symptoms and self-assessed health and completed the Stanford Modified Health Assessment Questionnaire. A series of 3 shoulder maneuvers was used to assess shoulder mobility and pain. The presence of diabetes and statin use was documented. A more thorough chart review was performed on individuals who reported shoulder pain and disability. Severe shoulder pain was common in the study group, reported by 31% of all participants. Functional limitation measured by the Modified Health Assessment Questionnaire and answering "yes" to greater difficulty performing daily tasks was associated with reduced internal rotation, which was present in almost 36% of all participants. Symptoms were often bilateral. No statistically significant risk factors emerged in this small sample, but suggestive trends were apparent. Interestingly, few patients reported discussing these problems with their providers, and shoulder-related problems were documented in only 10% of corresponding problem lists of symptomatic patients. With an aging population, the high prevalence of shoulder pain may have considerable impact on public health. It will become increasingly important to define risk factors, delineate etiologies, and devise new management strategies for patients with symptomatic shoulder disease.

A reverse shoulder arthroplasty with increased offset for the treatment of cuff-deficient shoulders with glenohumeral arthritis.

Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept have raised a renewed interest in less-medialised designs and techniques. The aim of this study was to evaluate the outcome of reverse shoulder arthroplasty (RSA) with the fully-constrained, less-medialised, Bayley-Walker prosthesis performed for the treatment of rotator-cuff-deficient shoulders with glenohumeral arthritis. A total of 97 arthroplasties in 92 patients (53 women and 44 men, mean age 67 years (standard deviation (sd) 10, (49 to 85)) were retrospectively reviewed at a mean follow-up of 50 months ((sd 25) (24 to 96)). The mean Oxford shoulder score and subjective shoulder value improved from 47 (sd 9) and 24 points (sd 18) respectively before surgery to 28 (sd 11) and 61 (sd 24) points after surgery (p < 0.001). The mean pain at rest decreased from 5.3 (sd 2.8) to 1.5 (sd 2.3) (p < 0.001). The mean active forward elevation and external rotation increased from 42(°)(sd 30) and 9(°) (sd 15) respectively pre-operatively to 78(°) (sd 39) and 24(°) (sd 17) post-operatively (p < 0.001). A total of 20 patients required further surgery for complications; 13 required revision of components. No patient developed scapular notching. The Bayley-Walker prosthesis provides reliable pain relief and reasonable functional improvement for patients with symptomatic cuff-deficient shoulders. Compared with other designs of RSA, it offers a modest improvement in forward elevation, but restores external rotation to some extent and prevents scapular notching. A longer follow-up is required to assess the survival of the prosthesis and the clinical performance over time.

Shoulder function after surgical treatment of displaced fractures of the humeral shaft: a randomized trial comparing antegrade intramedullary nailing with minimally invasive plate osteosynthesis

Minimally invasive plate osteosynthesis for humeral shaft fractures has been described recently, but there are no randomized studies comparing the clinical results for shoulder function between this technique and locking intramedullary nailing. A prospective randomized study was performed. Forty-one humeral shaft fractures (40 patients) were randomized to be treated with a minimally invasive plate (n=21) or a locking intramedullary nail (n=19). Clinical and radiographic outcome assessments were conducted at 1year postoperatively. Shoulder function was the primary outcome, as measured by the University of California, Los Angeles Shoulder Scale. Elbow function was measured by the Broberg-Morrey score, and fracture consolidation and complications were the main secondary outcomes. At 1year postoperatively, no significant difference was found with regard to shoulder function according to the University of California, Los Angeles scale between the minimally invasive plate and locking intramedullary nail (31.4 points vs 31.2 points, P=.98). There was also no difference in elbow function (94.8 points vs 94.1 points, P=.96). Complications were similar between the groups, without significant differences regarding infection (P>.99), symptomatic shoulder stiffness (P=.488), and neurapraxia of the lateral cutaneous nerve of the forearm (P=.475). Fracture union was achieved in all but 1 patient (2.4%) in the intramedullary nail group within 1year after the surgical procedure. There is no significant difference in shoulder function between antegrade intramedullary nailing and minimally invasive plate osteosynthesis for the treatment of displaced humeral shaft fractures, despite the limited power of our study.

Prevalence of and risk factors for asymptomatic rotator cuff tears in postmenopausal women

Rotator cuff tendon tears increase with age, but no study has specifically addressed prevalence changes in women from premenopause to postmenopause. The aims of this study were to evaluate the prevalence of rotator cuff asymptomatic tears in postmenopausal women and to study their relationship with anthropometric and metabolic measures. Premenopausal and postmenopausal women who were free from shoulder pain/functional impairment were enrolled. Body mass index (BMI), fasting glucose, triglycerides, total cholesterol, and high-density lipoprotein (HDL) cholesterol were evaluated. Both shoulders were examined by ultrasound imaging. For the purposes of this study, only full-thickness tears (classified as small, large, or massive) were taken into account. The prevalence of full-thickness tears (mainly localized in the supraspinatus tendon of the dominant side) was significantly higher in the postmenopausal group (8.9% vs 3.1%), with small, medium, and large tears in 60%, 20%, and 20% of cases, respectively. In women with tears, intragroup comparison showed significantly higher values for BMI and fasting glucose, and lower levels of HDL cholesterol; no difference was found for triglycerides and total cholesterol in premenopausal and postmenopausal women, respectively. On multiple logistic regression analysis, the probability of detecting a tear in both groups was positively related to high values of BMI and lower levels of HDL cholesterol. The prevalence of asymptomatic full-thickness tears is increased in the postmenopausal period, and there is an association between tears and metabolic disorders. Because asymptomatic tears have a great potential to evolve into symptomatic painful shoulder, a precocious discovery of this pathology may allow the planning of preventive and therapeutic measures.

Arthroscopic Subacromial Decompression for Small and Medium Size Tears of Rotator Cuff without Tendon Repair

According to our previous clinical impression, we hypothesized that patients who had symptomatic rotator cuff tendon tear in a diamemter below 3 cm would benefit from arthroscopic subacromial decompression only, without the need for the repair of the thorn tendon. From 1998 to 2003, 160 patients (168 shoulders) had arthroscopic subacromial decompression for impingement syndrome with a torn rotator cuff without repairing the tear of the cuffs (120 males and 40 females). The average patient age was 64 years and the average follow up was 30 months. At follow up, 96 patients (60%) had full recovery; 55 patients (35%) had residual low grade shoulder pain on effort and 7 patients (5%) had poor outcome. In the last group of patients with unsatisfactory outcome, the postoperative Constant score was only 64 points. In 95% of patients, the average Constant score values raised from average preoperative value of 62 to postoperative average score of 82. According to these results, there is an indication that in patients in the seventh decade of life or older with symptomatic rotator cuff tear, pain relief and good shoulder function can be achieved by more conservative approach of subacromial decompression alone, providing a clear diagnosis that the diameter of the tear in the supraspinatus and infraspinatus tendons is below 3 cm.

Measurement of volumetric bone mineral density in proximal humerus using quantitative computed tomography in patients with unilateral rotator cuff tear

The first purpose of this study was to reveal the clinically important region-specific volumetric bone mineral density (vBMD) of the proximal humerus in patients with unilateral rotator cuff tear (RCT), and the second was to evaluate the relationship between vBMD of the proximal humerus and BMD of the hip and lumbar spine measured using conventional dual-energy X-ray absorptiometry. Finally, we assessed whether any clinical factor could predict local osteoporosis of the proximal humerus. The study enrolled 65 patients who underwent arthroscopic repair of a unilateral RCT between April 2010 and July 2011 and had computed tomography scans of bilateral proximal humeri. Considering the suture bridge technique for RCT repair to be the leading treatment, region-specific BMD was measured in 7 volumetric blocks in the proximal humerus. Image and quantification processing was used to calculate the vBMD of each block. The vBMD values in all 7 blocks of the symptomatic shoulder were significantly lower than those of the asymptomatic contralateral shoulder (P < .05). Regardless of RCT, the greater tuberosity showed significant location-dependence in vBMD value; that is, the vBMD value was the highest in the posterolateral portion and the lowest in the medial portions. No significant correlation was found between vBMD of the greater tuberosity and clinical factors except female gender. The present study demonstrated the regional and bilateral differences in vBMD within the greater tuberosity in patients with unilateral RCT. Aside from female gender, no other clinical factors presented as risk factors for a higher possibility of osteoporosis.

Quantification of sonographic echogenicity by the gray-level histogram in patients with supraspinatus tendinopathy.

The aim of this study was to compare the gray-level value of the supraspinatus tendon of a painful shoulder with that of a normal shoulder measured by ultrasonography, and to investigate whether a low mean gray-level value of the supraspinatus tendon could indicate a partial-thickness or incomplete full-thickness tear. Two hundred and ten patients had significant unilateral shoulder pain with the clinical suspicion of rotator cuff tendinopathy. They underwent bilateral shoulder ultrasonography, and the mean echogenicity of the histogram was calculated on the screen. The mean gray-level value of each patient's contralateral asymptomatic shoulder was compared with that of the painful shoulder. Based on the scan of transverse and longitudinal planes, a significant difference existed between the symptomatic shoulder and contralateral asymptomatic shoulder (p<0.0001). The mean gray-level values of symptomatic shoulders showed no statistically significant difference between the patients who underwent surgery and the patients who underwent conservative treatment. We demonstrated that the ultrasound gray-level histogram is a promising tool for detecting the hypoechogenic appearance of supraspinatus tendinopathy. A decrease in the mean gray-level value on the symptomatic shoulder may be used as an alternative sonographic indicator of rotator cuff partial-thickness tear or tendinopathy. Diagnostic level III.