Identification and management of chronic shoulder pain in the presence of an MRA-confirmed humeral avulsion of the inferior glenohumeral ligament (HAGL) lesion

OBJECTIVE

To present the assessment and conservative management of chronic shoulder pain in the presence of a humeral avulsion of the inferior glenohumeral ligament (HAGL) lesion in an active individual.

CLINICAL FEATURES

A 47 year-old female office-worker with constant, deep, right shoulder pain with occasional clicking and catching claimed to have "tore something" in her right shoulder five years ago while performing reverse bicep curls. A physical exam led to differential diagnoses of a Superior Labrum Anterior to Posterior (SLAP) lesion, Bankart lesion, and bicipital tendinopathy. A Magnetic Resonance Arthrogram revealed a HAGL lesion.

INTERVENTION AND OUTCOME

A conservative chiropractic treatment plan in addition to physical therapy was initiated. The patient reported 75% improvement in symptoms after 4 treatments over a four-week duration.

SUMMARY

This case demonstrates the successful implementation of a conservative plan of management suggesting that the treatment provided to this patient should be considered and attempted prior to arthroscopic surgery.

Clinical evidence in the treatment of rotator cuff tears with hyaluronic acid

PURPOSE

the aim of this quantitative review is to document potential benefit and adverse effects of hyaluronic acid (HA) injection into the shoulder with rotator cuff tears.

METHODS

a systematic literature search was performed in english PubMed, Medline, Ovid, Google Scholar and Embase databases using the combined key words "hyaluronic acid", "rotator cuff tear", "hyaluronate", "shoulder", "viscosupplementation", with no limit regarding the year of publication. Articles were included if they reported data on clinical and functional outcomes, complications in series of patients who had undergone HA injection for management of rotator cuff tears. Two Authors screened the selected articles for title, abstract and full text in accordance with predefined inclusion and exclusion criteria. The papers were accurately analyzed focusing on objective rating scores reported.

RESULTS

a total of 11 studies, prospective, 7 were randomized were included by full text. A total of 1102 patients were evaluated clinically after different HA injection compare with corticosteroid injection, physically therapies, saline solution injection and control groups. The use of HA in patients with rotator cuff tears improve VAS and functional score in all trials that we have analyzed.

CONCLUSION

intra-articular injection with HA is effective in reducing pain and improving function in shoulder with rotator cuff tears and without severe adverse reaction.

LEVEL OF EVIDENCE

Level I.

The effect of sagittal rotation of the glenoid on axial glenoid width and glenoid version in computed tomography scan imaging

BACKGROUND

Computed tomography (CT) scans of the shoulder are often not well aligned to the axis of the scapula and glenoid. The purpose of this paper was to determine the effect of sagittal rotation of the glenoid on axial measurements of anterior-posterior (AP) glenoid width and glenoid version attained by standard CT scan. In addition, we sought to define the angle of rotation required to correct the CT scan to optimal positioning.

METHODS

A total of 30 CT scans of the shoulder were reformatted using OsiriX software multiplanar reconstruction. The uncorrected (UNCORR) and corrected (CORR) CT scans were compared for measurements of both (1) axial AP glenoid width and (2) glenoid version at 5 standardized axial cuts.

RESULTS

The mean difference in glenoid version was 2.6% (2° ± 0.1°; P = .0222) and the mean difference in AP glenoid width was 5.2% (1.2 ± 0.42 mm; P = .0026) in comparing the CORR and UNCORR scans. The mean angle of correction required to align the sagittal plane was 20.1° of rotation (range, 9°-39°; standard error of mean, 1.2°).

CONCLUSION

These findings demonstrate that UNCORR CT scans of the glenohumeral joint do not correct for the sagittal rotation of the glenoid, and this affects the characteristics of the axial images. Failure to align the sagittal image to the 12-o'clock to 6-o'clock axis results in measurement error in both glenoid version and AP glenoid width. Use of UNCORR CT images may have notable implications for decision-making and surgical treatment.

Return to play and recurrent instability after in-season anterior shoulder instability: a prospective multicenter study

BACKGROUND

There is no consensus on the optimal treatment of in-season athletes with anterior shoulder instability, and limited data are available to guide return to play.

PURPOSE

To examine the likelihood of return to sport and the recurrence of instability after an in-season anterior shoulder instability event based on the type of instability (subluxation vs dislocation). Additionally, injury factors and patient-reported outcome scores administered at the time of injury were evaluated to assess the predictability of eventual successful return to sport and time to return to sport during the competitive season.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

Over 2 academic years, 45 contact intercollegiate athletes were prospectively enrolled in a multicenter observational study to assess return to play after in-season anterior glenohumeral instability. Baseline data collection included shoulder injury characteristics and shoulder-specific patient-reported outcome scores at the time of injury. All athletes underwent an accelerated rehabilitation program without shoulder immobilization and were followed during their competitive season to assess the success of return to play and recurrent instability.

RESULTS

Thirty-three of 45 (73%) athletes returned to sport for either all or part of the season after a median 5 days lost from competition (interquartile range, 13). Twelve athletes (27%) successfully completed the season without recurrence. Twenty-one athletes (64%) returned to in-season play and had subsequent recurrent instability including 11 recurrent dislocations and 10 recurrent subluxations. Of the 33 athletes returning to in-season sport after an instability event, 67% (22/33) completed the season. Athletes with a subluxation were 5.3 times more likely (odds ratio [OR], 5.32; 95% CI, 1.00-28.07; P = .049) to return to sport during the same season when compared with those with dislocations. Logistic regression analysis suggests that the Western Ontario Shoulder Instability Index (OR, 1.05; 95% CI, 1.00-1.09; P = .037) and Simple Shoulder Test (OR, 1.03; 95% CI, 1.00-1.05; P = .044) administered after the initial instability event are predictive of the ability to return to play. Time loss from sport after a shoulder instability event was most strongly and inversely correlated with the Simple Shoulder Test (P = .007) at the time of initial injury.

CONCLUSION

In the largest prospective study evaluating shoulder instability in in-season contact athletes, 27% of athletes returned to play and completed the season without subsequent instability. While the majority of athletes who return to sport complete the season, recurrent instability events are common regardless of whether the initial injury was a subluxation or dislocation.

Shoulder arthroplasty for the treatment of postinfectious glenohumeral arthritis

BACKGROUND

Shoulder arthroplasty after native shoulder infection is an uncommon problem with limited outcomes data. The purpose of this study was to evaluate the rates of reinfection and clinical outcomes after shoulder arthroplasty for the treatment of postinfectious glenohumeral arthritis.

METHODS

Between 1977 and 2009, 24 shoulders underwent shoulder arthroplasty for postinfectious glenohumeral arthritis. Twenty-three were monitored for a minimum of 2 years (mean, 8.3 years) or until reoperation. Complications and clinical and radiographic results were documented at the most recent follow-up.

RESULTS

Of the 23 shoulders, 23 had no pain or mild or moderate pain after vigorous activity. Pain scores improved from 4.5 to 2.1 points after shoulder arthroplasty (P < .001). The mean shoulder abduction improved from 62° to 110° (P < .001), and the mean external rotation improved from 14° to 47° (P < .001). Subjectively, the result in 16 of the 23 shoulders was rated as much better or better. Five shoulders required reoperation, with 2 having an infectious cause. The Neer rating was excellent in 2 shoulders, satisfactory or successful in 9, and unsatisfactory or unsuccessful in 12. Radiographic follow-up showed 3 glenoids and 3 humeral components were at risk for loosening.

CONCLUSIONS

Shoulder arthroplasty for the treatment of the sequelae of an infected shoulder can be performed with a low risk of reinfection. The higher-than-expected rate of clinical or radiographic loosening remains concerning for culture negative infection. Although overall pain and motion can be expected to improve, unsatisfactory clinical results are not uncommon and may be secondary to the initial insult of infection.

Glenohumeral joint injections: a review

Context:

Intra-articular injections into the glenohumeral joint are commonly performed by musculoskeletal providers, including orthopaedic surgeons, family medicine physicians, rheumatologists, and physician assistants. Despite their frequent use, there is little guidance for injectable treatments to the glenohumeral joint for conditions such as osteoarthritis, adhesive capsulitis, and rheumatoid arthritis.

Evidence Acquisition:

We performed a comprehensive review of the available literature on glenohumeral injections to help clarify the current evidence-based practice and identify deficits in our understanding. We searched MEDLINE (1948 to December 2011 [week 1]) and EMBASE (1980 to 2011 [week 49]) using various permutations of intra-articular injections AND (corticosteroid OR hyaluronic acid) and (adhesive capsulitis OR arthritis).

Results:

We identified 1 and 7 studies that investigated intra-articular corticosteroid injections for the treatment of osteoarthritis and adhesive capsulitis, respectively. Two and 3 studies investigated the use of hyaluronic acid in osteoarthritis and adhesive capsulitis, respectively. One study compared corticosteroids and hyaluronic acid injections in the treatment of osteoarthritis, and another discussed adhesive capsulitis.

Conclusion:

Based on existing studies and their level of evidence, there is only expert opinion to guide corticosteroid injection for osteoarthritis as well as hyaluronic acid injection for osteoarthritis and adhesive capsulitis.

The effect of exercise-based management for multidirectional instability of the glenohumeral joint: a systematic review

BACKGROUND

The most commonly recommended treatment for multidirectional instability (MDI) of the glenohumeral joint is exercise-based management. The primary objective of this review was to evaluate the effectiveness of exercise-based management in patients with MDI. The secondary aim was to observe the types of exercise protocols and outcomes used, as well as any adverse results associated with exercise.

METHODS

The Cochrane Database of Systematic Reviews, Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PEDro, Current Contents, Allied and Complementary Medicine (AMED), Australasian Medical Index (AMI), Ausport, and Clinical Trials Registers were searched for published and unpublished studies from the inception date to June 2012 using the keywords multidirectional instability, glenohumeral, and exercise. Selection criteria included all study designs (except case reports and case series) and participants with clinically diagnosed MDI using exercise-based management. Inclusion criteria were not limited by outcomes. The authors' own risk-of-bias tool was used for quality assessment of studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to synthesize the evidence.

RESULTS

The risk of bias was high in all 7 included studies. For before-and-after comparisons of exercise-based management, GRADE assessment showed very low-quality evidence for improvements in shoulder kinematics, the Rowe score, overall status rating, and peak muscle strength.

CONCLUSIONS

The effect of exercise-based management on MDI was variable across the included studies because of study heterogeneity and a high level of bias. There is a need for high-quality intervention studies to be undertaken to validate the effect of exercise for MDI.

Glenohumeral relationships: subchondral mineralization patterns, thickness of cartilage, and radii of curvature

Subchondral mineralization represents the loading history of a joint and can be measured in vivo using computed tomography osteoabsorptiometry. Different mineralization patterns in the glenohumeral joint have been explained by the principle of physiologic incongruence. We sought to support this explanation by measurement of mineralization, radii, and cartilage thickness in 18 fresh shoulder specimens. We found three mineralization patterns: bicentric, monocentric anterior, and monocentric central. Mean radii of the glenoids were 27.4 mm for bicentric glenoids, 27.3 mm for monocentric anterior, and 24.8 mm for monocentric central glenoids. Cartilage thickness measurement revealed the highest values in anterior parts; the thinnest cartilage was found centrally. Our findings support the principle of a physiologic incongruence in the glenohumeral joint. Bicentric mineralization patterns exist in joints consisting of more flat glenoids compared to the corresponding humeral head. Monocentric distribution with a central maximum was found in specimens with glenoids being more curved, indicating higher degrees of congruence, which might represent an early stage of degenerative disease. The obtained information might also be important for implant fixation in resurfacing procedures or to achieve the best possible fit of an osteochondral allograft in the repair of cartilage defects.

The recognition and treatment of superior labral (slap) lesions in the overhead athlete

The overhead athlete presents with a unique profile that may predispose them to specific pathology. Injury to the superior aspect of the glenoid labrum (SLAP lesions) poses a significant challenge to the rehabilitation specialist due to the complex nature and wide variety of etiological factors associated with these lesions. A thorough clinical evaluation and proper identification of the extent of labral injury is important in order to determine the most appropriate non-operative and/or surgical management. Postoperative rehabilitation is based on the specific surgical procedure that has been performed, as well as the extent, location, and mechanism of labral pathology and associated lesions. Emphasis is placed on protecting the healing labrum while gradually restoring range of motion, strength, and dynamic stability of the glenohumeral joint. The purpose of this paper is to provide an overview of the anatomy and pathomechanics of SLAP lesions and review specific clinical examination techniques used to identify these lesions in the overhead athlete. Furthermore, a review of the current surgical management and postoperative rehabilitation guidelines is provided.

LEVEL OF EVIDENCE

5.

Comprehensive post-arthroscopic management of a middle-aged adult with glenohumeral osteoarthritis: a case report

Comprehensive Arthroscopic Management (CAM) is a new glenohumeral debridement procedure developed as a joint preserving alternative to total shoulder arthroplasty (TSA). The procedure consists of several arthroscopic components including: A. scar tissue and chondral debridement, B. synovectomy, C. inferior humeral osteoplasty, D. capsular release, E. axillary nerve decompression, and F. tenodesis of the long head of the biceps. In this case, an active, middle age patient who failed physical therapy treatment and corticosteroid injections was evaluated and diagnosed with glenohumeral osteoarthritis. Anterior- posterior (AP) and axillary radiographs showed grade IV changes of the articular cartilage, confirming the diagnosis. The patient was not an ideal candidate for TSA because of her age, activity level, and concern for implant survival; therefore surgical intervention was performed using the CAM procedure. After the surgery, the patient demonstrated increased joint space as shown using radiographic imaging. The patient underwent intensive postoperative rehabilitation with a heavy emphasis on joint range of motion (ROM) and capsular mobility. By eight weeks she achieved 85% active ROM compared to her uninvolved shoulder, and a 55% improvement on the Pennsylvania Shoulder Score. Radiographic imaging provided an understanding of the severity of the arthritic changes present in this patient, identified the limited potential of continued conservative management, and showed structural changes that may be correlated with improved function following the surgical intervention. For patients less than 55 years of age diagnosed with severe glenohumeral osteoarthritis, the CAM procedure and intensive, motion focused therapy presents a promising treatment combination.

LEVEL OF EVIDENCE

IIIb.

Reliability of a set of protractors for direct anatomical measurements around the glenoid and humeral head rims

Functional biomechanics studies of the glenohumeral (GH) soft tissues require an understanding of their sites of bony attachment. Anatomical positions of GH capsular structures have often been quantified relative to the rims of the glenoid and humeral head (HH). The aim of this study was twofold: (1) to quantify the reliability of a set of protractors that directly fit on to the glenoid and HH rims and (2) to use this to determine direct angular position referencing of landmarks and soft tissue attachment points. Three assessors independently used the protractors to assess nine prescribed landmarks on 30 dry bone specimens (15 glenoids and 15 HHs) recording the angular positions of the structures relative to the glenoid and HH. The collected data showed high levels of validity as indicated by the protractor's intra- and inter-assessor reliabilities: 98.2 and 98.7% for the glenoid component, and 96.2 and 96.5% for the humeral component, respectively. The device could be useful in anatomical studies, description of defects and pathologies on glenohumeral articulation, and planning of scapular reconstructive surgery.

The effects of anthropometric scaling parameters on normalized muscle strength in uninjured baseball pitchers

CONTEXT

Muscle force must be normalized for between-subjects comparisons of strength to be valid. The most effective method for normalizing muscle strength has not, however, been systematically evaluated.

OBJECTIVE

To evaluate the effects of normalizing muscle strength using a spectrum of anthropometric parameters.

DESIGN

Cross-sectional.

SETTING

Laboratory.

PARTICIPANTS

50 uninjured high-school-age baseball pitchers.

INTERVENTIONS

Shoulder-rotation strength was tested at 0° and 90° abduction with a handheld dynamometer. Muscle force was normalized to parameters including subject height, weight, height × weight, body-mass index (BMI), forearm length, and forearm length × height.

OUTCOME MEASURES

Statistical analysis included evaluating the coefficient of variation, skewness, and kurtosis of the nonnormalized and normalized muscle force. The most effective normalization method was determined based on the scaling factor that yielded the lowest variability for the data set and promoted the most normal distribution of the data set.

RESULTS

Using body weight to scale muscle force was the most effective anthropometric parameter for normalizing strength values based on the group of statistical measures of variability. BMI, height × weight, and forearm length × weight as scaling factors also yielded less variable values for muscle strength compared with nonnormalized strength, but less consistently than body weight. Height and forearm length were least effective in reducing the variability of the data set relative to nonnormalized muscle force.

CONCLUSION

This study provides objective support for scaling muscle strength to subject body weight. This approach to normalizing muscle strength uses methods readily accessible to clinicians and researchers and may facilitate the identification of differences in strength between individuals with diverse physical characteristics.

Glenohumeral Microfracture

The treatment of symptomatic cartilage lesions in the glenohumeral joint presents a significant challenge due to poor healing characteristics. Diagnosis of glenohumeral chondral defects is not always clear, and while current imaging modalities are good, many lesions require arthroscopy to fully appreciate. Arthroplasty remains an effective treatment in low-demand patients; however, younger, higher demand individuals may be treated with less invasive reparative measures. This paper discusses the diagnosis of glenohumeral chondral pathology and presents the technique, rehabilitation, and available outcomes following microfracture in the shoulder.

In vivo assessment of scapulohumeral rhythm during unconstrained overhead reaching in asymptomatic subjects

BACKGROUND

The contribution of scapulothoracic and glenohumeral motion to overall shoulder motion remains difficult to determine. We sought to determine the exact ratio between these two motion components in order to better understand overall shoulder kinematics in asymptomatic individuals in unconstrained reaching.

MATERIALS AND METHODS

This study assessed shoulder motion using bone-fixed sensors to quantify scapulohumeral motion during unconstrained raising and lowering of the arm. Electromagnetic tracking devices rigidly fixed to bone pins recorded active scapular and humeral motion.

RESULTS

We found a significant difference in the ratio of glenohumeral elevation to scapular upward rotation during arm raising (2.3) and lowering (2.7). Each degree of glenohumeral elevation yielded scapular upward rotation of 0.43 degrees (raising) compared with downward rotation of 0.37 degrees (lowering), across the motion arc. Until 125 degrees of glenohumeral elevation, the scapula internally rotated and then externally rotated with further elevation. Scapular upward rotation and posterior tilting progressively increased until maximal elevation. Scapulohumeral rhythm was greatest in the first increment of raising the arm and higher overall when lowering the arm.

DISCUSSION

Understanding these data allows improved evaluation of potential motion abnormalities in patients with shoulder pathology and may improve treatment for restoration of normal shoulder motion.

Scapular-Positioning Patterns During Humeral Elevation in Unimpaired Shoulders

OBJECTIVE: To assess scapular-positioning patterns using a static measurement technique. DESIGN AND SETTING: We used a 4-within-factor design to compare scapular upward rotation among subjects. The within factors included side (dominant, nondominant), plane of motion (scapular, sagittal), direction of motion (ascending, descending), and level of humeral rotation (rest, 30 degrees, 60 degrees, 90 degrees, 120 degrees ). SUBJECTS: Twenty-seven subjects with unimpaired shoulders. MEASUREMENTS: We measured scapular position and glenohumeral range of motion using a digital inclinometer and goniometer, respectively. All measurements were performed bilaterally. RESULTS: Between-session repeatability was poor to excellent depending on humeral-elevation angle. The scapular plane demonstrated significantly more scapular upward rotation than did the sagittal plane at 120 degrees of humeral elevation. CONCLUSIONS: The scapula demonstrated a consistent pattern of downward rotation initially from rest to 30 degrees of humeral elevation, followed by an upward rotation after 30 degrees of humeral elevation to the highest level (120 degrees ). Scapular upward rotation is greater in the scapular plane than in the sagittal plane. Therefore, overhead rehabilitation exercises should be performed in the scapular plane, especially in subjects with rotator cuff tendinopathy.

Pathophysiology of anterior shoulder instability

OBJECTIVE

To review some of the important biomechanical factors that provide glenohumeral stability, along with the pathologic mechanisms involved in glenohumeral instability of the shoulder.

DATA SOURCES

Current English medical literature concerning the multiple pathologic factors involved in glenohumeral instability was reviewed.

DATA SYNTHESIS

Multiple dynamic and static factors control glenohumeral instability. Knowledge of normal shoulder anatomy and biomechanics is necessary to interpret pathologic events.

CONCLUSIONS/RECOMMENDATIONS

Dynamic and static factors collectively provide stability to the glenohumeral joint. Disruption or malfunction of these factors causes dysfunction in the shoulder.

The laser-assisted capsular shift procedure on an intercollegiate volleyball player: a case report

OBJECTIVE

To present a new arthroscopic technique, the laser-assisted capsular shift (LACS), which decreases glenohumeral instability and reduces recovery time over traditional surgical procedures.

BACKGROUND

A student-athlete hyperabducted her right shoulder while diving for a ball during a volleyball match. She complained of pain, weakness, and inability to raise her arm above shoulder height in any plane.

DIFFERENTIAL DIAGNOSIS

Capsular sprain, subluxation, rotator cuff strain, glenoid labral lesion.

TREATMENT

The student-athlete was unable to play due to pain and dysfunction and so elected to have the LACS procedure performed.

UNIQUENESS

The LACS procedure is a relatively new procedure for tightening the capsule and decreasing glenohumeral instability. Immobilization and recovery time are reduced when compared with traditional treatment methods.

CONCLUSIONS

The LACS procedure appears to be a good alternative to some of the traditional methods used to treat glenohumeral instability.

Open and closed kinetic chain exercises improve shoulder joint reposition sense equally in healthy subjects

OBJECTIVE

To compare the effects of open and closed kinetic chain exercise on shoulder joint reposition sense.

DESIGN AND SETTING

Subjects with no previous upper extremity injury participated in a 6-week exercise program consisting of 3 sessions per week.

SUBJECTS

Thirty-nine healthy male military cadets: 13 each in the open, closed, and control groups.

MEASUREMENTS

Each subject was pretested and posttested for both active and passive joint reposition sense at 30 degrees external rotation, 30 degrees internal rotation, and 10 degrees from full external rotation.

RESULTS

The open and closed kinetic chain groups de- creased in reposition sense error scores in comparison with the control group, but no difference was found between the 2 training groups.

CONCLUSION

Our findings suggest that shoulder joint reposition sense can be enhanced with training in healthy subjects. Also, open and closed kinetic chain exercises appear to be equally effective in improving shoulder joint reposition sense.