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Baek CH, Kim JG, Kim BT. Long-term outcomes of anterior latissimus dorsi tendon transfer for irreparable subscapularis tears. Bone Joint J 2024; 106-B:957-963. [PMID: 39216861 DOI: 10.1302/0301-620x.106b9.bjj-2024-0099.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Aims Favourable short-term outcomes have been reported following latissimus dorsi tendon transfer for patients with an irreparable subscapularis (SSC) tendon tear. The aim of this study was to investigate the long-term outcomes of this transfer in these patients. Methods This was a retrospective study involving 30 patients with an irreparable SSC tear and those with a SSC tear combined with a reparable supraspinatus tear, who underwent a latissimus dorsi tendon transfer. Clinical scores and active range of motion (aROM), SSC-specific physical examination and the rate of return to work were assessed. Radiological assessment included recording the acromiohumeral distance (AHD), the Hamada grade of cuff tear arthropathy and the integrity of the transferred tendon. Statistical analysis compared preoperative, short-term (two years), and final follow-up at a mean of 8.7 years (7 to 10). Results There were significant improvements in clinical scores, in the range and strength of internal rotation and aROM compared with the preoperative values in the 26 patients (87%) who were available for long-term follow-up. These improvements were maintained between short- and long-term follow-ups. Although there was a decreased mean AHD of 7.3 mm (SD 1.5) and an increased mean Hamada grade of 1.7 (SD 0.5) at final follow-up, the rate of progression of cuff tear arthropathy remained low-grade. Comparison between the isolated SSC and combined SSC and reparable supraspinatus tear groups showed no significant differences. At final follow-up, one patient (3.8%) had undergone revision surgery to a reverse shoulder arthroplasty (RSA). No neurological complications were associated with the procedure. Conclusion Latissimus dorsi transfer for an irreparable SSC tendon tear resulted in a significant clinical improvement, particularly in pain, range and strength of internal rotation and aROM, which were maintained over a mean of 8.7 years following surgery. Given that this was a long-term outcome study, there was a low-grade progression in the rate of cuff tear arthropathy. Thus, the long-term clinical efficacy of latissimus dorsi tendon transfer in patients with irreparable SSC was confirmed as a joint-preserving procedure for these patients, suggesting it as an effective alternative to RSA in young, active patients without degenerative changes of the glenohumeral joint.
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Affiliation(s)
- Chang H Baek
- Department of Orthopaedic Surgery, Yeosu Baek Hospital, Jeollanam-do, South Korea
| | - Jung G Kim
- Department of Orthopaedic Surgery, Yeosu Baek Hospital, Jeollanam-do, South Korea
| | - Bo T Kim
- Department of Orthopaedic Surgery, Yeosu Baek Hospital, Jeollanam-do, South Korea
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Marth AA, Spinner GR, von Deuster C, Sommer S, Sutter R, Nanz D. Activation patterns of rotator-cuff muscles from quantitative IVIM DWI after physical testing. Eur Radiol Exp 2024; 8:96. [PMID: 39186226 PMCID: PMC11347545 DOI: 10.1186/s41747-024-00487-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 06/18/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND The diagnostic value of clinical rotator cuff (RC) tests is controversial, with only sparse evidence available about their anatomical specificity. We prospectively assessed regional RC muscle activation patterns by means of intravoxel incoherent motion (IVIM) diffusion-weighted magnetic resonance imaging (MRI) after the execution of common clinical RC tests. METHODS Ten healthy subjects (five males, five females) underwent three sessions of diffusion-weighted 3-T shoulder MRI before and after testing the supraspinatus (SSP, Jobe test, session 1), subscapularis (SSC, lift-off test, session 2, at least 1 week later), and infraspinatus muscle (ISP, external rotation test, session 3, another week later). IVIM parameters (perfusion fraction, f; pseudo-diffusion coefficient. D*; and their product, fD*) were measured in regions of interest placed in images of the SSP, SSC, ISP, and deltoid muscle. The Wilcoxon signed-rank test was used for group comparisons; p-values were adjusted using the Bonferroni correction. RESULTS After all tests, fD* was significantly increased in the respective target muscles (SSP, SSC, or ISP; p ≤ 0.001). After SSP testing, an additional significant increase of fD* was observed in the deltoid, the SSC, and the ISP muscle (p < 0.001). After the SSC and ISP tests, no significant concomitant increase of any parameter was observed in the other RC muscles. CONCLUSION IVIM revealed varying activation patterns of RC muscles for different clinical RC tests. For SSP testing, coactivation of the deltoid and other RC muscles was observed, implying limited anatomical specificity, while the tests for the SSC and ISP specifically activated their respective target muscle. RELEVANCE STATEMENT Following clinical RC tests, IVIM MRI revealed that SSP testing led to shoulder muscle coactivation, while the SSC and ISP tests specifically activated the target muscles. KEY POINTS In this study, intravoxel incoherent motion MRI depicted muscle activation following clinical rotator cuff tests. After supraspinatus testing, coactivation of surrounding shoulder girdle muscles was observed. Subscapularis and infraspinatus tests exhibited isolated activation of their respective target muscles.
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Affiliation(s)
- Adrian Alexander Marth
- Swiss Center for Musculoskeletal Imaging (SCMI), Balgrist Campus AG, Zurich, Switzerland.
- Department of Radiology, Balgrist University Hospital, Zurich, Switzerland.
| | - Georg Ralph Spinner
- Center of Computational Health, Institute of Computational Life Sciences, University of Applied Sciences (ZHAW), Wädenswil, Switzerland
| | - Constantin von Deuster
- Swiss Center for Musculoskeletal Imaging (SCMI), Balgrist Campus AG, Zurich, Switzerland
- Advanced Clinical Imaging Technology, Siemens Healthineers International AG, Zurich, Switzerland
| | - Stefan Sommer
- Swiss Center for Musculoskeletal Imaging (SCMI), Balgrist Campus AG, Zurich, Switzerland
- Advanced Clinical Imaging Technology, Siemens Healthineers International AG, Zurich, Switzerland
| | - Reto Sutter
- Department of Radiology, Balgrist University Hospital, Zurich, Switzerland
- Medical Faculty, University of Zurich (UZH), Zurich, Switzerland
| | - Daniel Nanz
- Swiss Center for Musculoskeletal Imaging (SCMI), Balgrist Campus AG, Zurich, Switzerland
- Medical Faculty, University of Zurich (UZH), Zurich, Switzerland
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Kim JH, Kim YS, Cho SH, Hong SA, Lee HJ. The Destiny of the Subscapularis Tendon after Arthroscopic Supraspinatus Repair. Clin Orthop Surg 2024; 16:594-601. [PMID: 39092311 PMCID: PMC11262948 DOI: 10.4055/cios23389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 03/23/2024] [Accepted: 03/27/2024] [Indexed: 08/04/2024] Open
Abstract
Background The purpose of this study was to identify the changes in untreated subscapularis in patients who underwent supraspinatus repair and to evaluate the factors related to the changes in the subscapularis. Methods A cohort of patients who underwent isolated supraspinatus repair with preservation of the subscapularis was reviewed. Changes in the subscapularis, including any newly formed lesion and aggravation of an existing lesion, were evaluated 12 months postoperatively on magnetic resonance imaging along with an examination to identify causative factors after supraspinatus repair. Clinical scores were compared between patients with and without subscapularis changes. Results A total of 528 patients were reviewed. Changes in the subscapularis, including newly formed lesions and aggravation of an existing lesion, were shown in 90 patients (17.0%). Upon regression analysis, changes in the subscapularis were associated with the initial existence of a subscapularis lesion (grade I: p = 0.042, grade II: p = 0.025), an accompanying biceps lesion (p = 0.038), and a retear of the repaired supraspinatus (p = 0.024). No significant differences were shown in clinical scores between patients with and without subscapularis changes after supraspinatus repair. Conclusions Untreated asymptomatic subscapularis may undergo morphological changes even after repair of the torn supraspinatus. Preoperative subscapularis lesions, biceps long head pathology, and retears of the repaired supraspinatus were associated with subscapularis pathology in patients who underwent supraspinatus repair.
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Affiliation(s)
- Jong-Ho Kim
- Department of Orthopedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yang-Soo Kim
- Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Hyun Cho
- Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-An Hong
- Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyo-Jin Lee
- Department of Orthopedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Kim HG, Kim SC, Park JH, Kim JS, Kim BT, Kim DY, Lee SM, Yoo JC. Diagnostic Performance of Belly-Press Angle in Predicting the Severity of Subscapularis Tear. Am J Sports Med 2023; 51:3226-3234. [PMID: 37681493 DOI: 10.1177/03635465231193956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
BACKGROUND Neglected partial subscapularis tears often cause functional impairment even after repair of the supraspinatus and infraspinatus tear is done. Numerous physical examinations for detecting partial subscapularis tears have been described in previous studies. PURPOSE To analyze the relationship between the preoperative clinical features and the severity of a partial subscapularis tear and to provide diagnostic clues for patients requiring subscapularis repair. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 2. METHODS This retrospective study included 286 patients who underwent arthroscopic shoulder surgery between 2020 and 2022. Preoperative clinical features, including range of motion, functional scores, muscle strength ratio, modified belly-press test (measuring belly-press angle), and bear-hug test, were collected. Magnetic resonance imaging (MRI) evaluation was done according to the Yoo and Rhee classification. Types of subscapularis tear, supraspinatus lesion, and biceps lesion were recorded during arthroscopic surgery. A comparison of preoperative clinical features between the no-repair group (type 2A or less) and surgical repair group (type 2B or more) was done. The optimal cutoff value of the belly-press angle was determined and the diagnostic performance of the belly-press angle, bear-hug test, and MRI were evaluated using the receiver operating characteristic curve. RESULTS Among 286 patients, 189 (66.1%) had subscapularis tears with type 2A or more. There was a significant difference in muscle strength ratio of the belly-press (P < .001), belly-press angle (P < .001), and bear-hug test (P < .001) between the no-repair group (type 2A or less) and the surgical repair group (type 2B or more). With a belly-press angle of 15° as a new cutoff value, the modified belly-press test showed 67.6% sensitivity, 73.9% specificity, and 69.6% accuracy in detecting type 2B or higher subscapularis tear. CONCLUSION Patients with type 2A and 2B subscapularis tears (according to the Yoo and Rhee classification) showed differences in belly-press strength ratio, belly-press angle, and bear-hug test. The cutoff value of the 15° belly-press angle showed an accuracy of 69.6% in detecting subscapularis tears with type 2B or higher.
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Affiliation(s)
- Hyun Gon Kim
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Su Cheol Kim
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong Hun Park
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Soo Kim
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Bo Taek Kim
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dae Yeung Kim
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang Min Lee
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Chul Yoo
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Saremi H, seifrabiei M. Subscapularis tendon tear classification and diagnosis: A systemic review and meta-analysis. Front Surg 2023; 10:916694. [PMID: 37009599 PMCID: PMC10050355 DOI: 10.3389/fsurg.2023.916694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 01/23/2023] [Indexed: 03/17/2023] Open
Abstract
BackgroundIn the current study, we performed a systematic review and meta-analysis regarding the comparison of accuracy, sensitivity, and specificity of the techniques in diagnosing SSC tendon tears. Also, we performed a systematic review of the classification of SSC tendon tears.MethodsEnglish language, peer-reviewed journal publications from the first date available to March 2022 were extracted by searching PubMed and Web of Science databases. A forest plot was used to graphically show the results of pooled sensitivity, specificity, and accuracy of different diagnostic modalities.ResultsThere were six studies on using MRI to diagnose subscapularis tendon tears, five studies on MRI, four studies on clinical examination, one on ultrasonography, and one on CT arthrography. Pooled sensitivity values for MRI, MRA, clinical examination, ultrasonography, and CT arthrography were 0.71 (CI: 0.54; 0.87), 0.83 (0.77; 0.88), 0.49 (0.31; 0.67), 0.39 (0.29; 0.51), and 0.90 (0.72–0.97), respectively. The pooled specificity values for MRI, MRA, clinical examination, ultrasonography, and CT arthrography were 0.93 (CI: 0.89; 0.96), 0.86 (0.75; 0.93), 0.89 (0.73; 0.96), 0.93 (0.88; 0.96), and 0.90 (0.69; 0.98), respectively. The pooled diagnostic accuracy values for MRI, MRA, clinical examination, ultrasonography, and CT arthrography were 0.84 (CI: 0.80; 0.88), 0.85 (0.77; 0.90), 0.76 (0.66; 0.84), 0.76 (0.70; 0.81), and 0.90 (0.78; 0.96), respectively.ConclusionAccording to our systematic review and meta-analysis, MR arthrography was the most accurate in diagnosing subscapularis tears. MR arthrography was the most sensitive, and MRI and ultrasonography were the most specific in detecting subscapularis tears.
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Affiliation(s)
- Hossein Saremi
- Department of Orthopedics, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
- Correspondence: Hossein Saremi
| | - Mohamadali seifrabiei
- Social Medicine Department, Community Medicine Specialist, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
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Uekama K, Miyazaki T, Maesako S, Kaieda H, Taniguchi N. Clinical significance of the elbow forward translation motion in patients with rotator cuff tears. JSES Int 2023. [DOI: 10.1016/j.jseint.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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Camenzind RS, Martin Becerra J, Tondelli TO, Gossing L, Serane-Fresnel J, Lafosse T, Lafosse L. Correlation between preoperative clinical examination and intraoperatively found subscapularis tendon tear. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:373-379. [PMID: 35006313 DOI: 10.1007/s00590-021-03197-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/29/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Analyze the diagnostic value for subscapularis (SSC) tendon tears, their correlation between pain and strength on clinical tests, and compare them with intraoperative arthroscopic findings to prove their diagnostic value. METHODS 110 consecutive patients undergoing arthroscopic rotator cuff repair were reviewed and allocated to isolated SSC (n = 39) and combined anterosuperior tendon tear (n = 71) groups and analyzed. Preoperative clinical testing included belly press (BPT), bear hug (BHT), lift-off (LOT), palm-up (PUT), and Jobe test (JT). All tests were performed in two categories: pain (in 4 categories: 0, 5, 10, and 15) and strength (from 0 to 5). The tendon tears were intraoperatively reviewed and classified. RESULTS Mean age was 59 years (SD 10). The sensitivity of the BHT was 88.2% and 74.5% for BPT, while specificity was only 41.9% for BHT and 45% for BPT. Sensitivity of JT was 90.5% and 87.5% for PUT, while specificity was only 41% for JT and 28.2% for PUT. A low positive correlation for an intraoperative SSC lesion and the strength of BPT (Spearman rank correlation - 0.425; p value < 0.0001) and the strength of BHT ( - 0.362; p value = 0.001) could be found. With linear regression analysis estimated by ordinary least squares, a correlation between BPT strength and surgical grade of SSC lesion (- 0.528; 95% CI, - 0.923 to - 0.133; pvalue < 0.01) was found. CONCLUSION The BHT showed a higher sensitivity for a SSC lesion, while the BPT had a higher correlation between preoperative testing, most notably internal rotation strength, and intraoperative surgical grade of the SSC tendon lesion. LEVEL OF EVIDENCE Level II, Prospective cohort study for Diagnostic tests.
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Affiliation(s)
- Roland Stefan Camenzind
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France.
- Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Javier Martin Becerra
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
- Ortomove, Centro Medico ABC, Av carlos graef Fernández 154 consultorio 0071, Santa Fe Cuajimalpa, 05300, Mexico City, Mexico
| | - Timo O Tondelli
- Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Louis Gossing
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
- Department of Orthopaedic Surgery, Braine-l'Alleud-Waterloo Hospital, Centre Hospitalier Interregional Edith Cavell (CHIREC), Braine-l'Alleud, Belgium
| | - Julien Serane-Fresnel
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
- IECEM - Research Unit, Polyclinique Saint Côme, Compiègne, France
| | - Thibault Lafosse
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
| | - Laurent Lafosse
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
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Baek CH, Kim JG, Baek GR. Outcomes of combined anterior latissimus dorsi and teres major tendon transfer for irreparable anterosuperior rotator cuff tears. J Shoulder Elbow Surg 2022; 31:2298-2307. [PMID: 35550431 DOI: 10.1016/j.jse.2022.03.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/22/2022] [Accepted: 03/27/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Irreparable anterosuperior rotator cuff tears (IASRCTs) can result in loss of active elevation, loss of internal rotation, and pseudoparalysis. Joint-preserving treatment options for IASRCTs in young and high-demand elderly patients are limited. The purpose of this study was to evaluate the clinical and radiologic outcomes of combined anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with IASRCTs without reconstruction of the superior rotator cuff and capsular portion. METHODS This retrospective study was conducted between 2015 and 2018. We included patients who underwent combined aLDTM tendon transfer for IASRCTs. Clinical outcomes included visual analog scale for pain, Constant score, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder scores, activities of daily living requiring active internal rotation score, active range of motion, subscapularis-specific physical examination, and rate of return to work. Radiographic analyses included the assessment of acromiohumeral distance, Hamada grade for cuff tear arthropathy, rate of anterior glenohumeral subluxation reduction, and transferred tendon integrity at 2 years postoperatively. RESULTS The mean follow-up period was 38.1 ± 13.7 (range: 24-63) months. Of the patients, 30 (mean age: 64.1 years) met the study criteria. Postoperatively, mean Constant, American Shoulder and Elbow Surgeons, University of California Los Angeles, and activities of daily living requiring active internal rotation scores improved from 47.4 to 69.9 (P < .001), 44.9 to 79.2 (P < .001), 20.0 to 28.7 (P < .001), and 13.2 to 26.9 (P < .001), respectively. The mean active range of motion was significantly increased postoperatively for both forward elevation (P < .001) and internal rotation at the back (P < .001). Of the patients, 24 (83%) returned to their previous work. No significant progression of cuff tear arthropathy was observed at final follow-up (Hamada grade: preoperative 1.3 ± 0.5 to postoperative 1.5 ± 0.7; p=0.155). Fifteen of 30 patients (50%) restored the anterior glenohumeral subluxation that was apparent preoperatively. One patient presented with transient axillary nerve palsy after surgery. Two patients presented with partial nonretracted tears of the transferred tendon. CONCLUSION This minimum 2-year follow-up study demonstrated that combined aLDTM tendon transfer without reconstruction of the superior rotator cuff and capsular portion was a viable treatment option with favorable clinical and radiologic outcomes for patients with IASRCTs.
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Affiliation(s)
- Chang Hee Baek
- Department of Orthopaedic Surgery, Yeosu Baek Hospital, Yeosu-si, Jeollanam-do, Republic of Korea.
| | - Jung Gon Kim
- Department of Orthopaedic Surgery, Yeosu Baek Hospital, Yeosu-si, Jeollanam-do, Republic of Korea
| | - Gyu Rim Baek
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
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Ito Y, Matsumoto H, Ishida T, Shimizu S, Oizumi N, Suenaga N. The influence of testing positions and resistance locations on muscle activities during shoulder internal rotation strength measurements in young healthy adults. J Orthop Sci 2022; 27:1246-1251. [PMID: 34535383 DOI: 10.1016/j.jos.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although some tests of shoulder internal rotator strength including subscapularis are commonly used in clinical practice, the differences in shoulder muscle activities other than subscapularis muscle among those tests are not well understood. The purpose of this study was to examine the activities of the superficial shoulder muscles in addition to internal rotation strength during two belly-press and three lift-off test positions. METHODS Thirteen healthy young adult men (age 29.5 ± 5.4 years) were recruited for the present study. They performed isometric shoulder internal rotation against manual resistance during the belly-press test positions with two different resistance locations and the lift-off test with three different arm positions. The surface electromyographic activities of the superficial shoulder muscles, including the deltoid (anterior, middle, posterior), pectoralis major, long head of triceps and latissimus dorsi muscle, were collected and compared between the two belly-press tests, and among the three lift-off test positions (P < 0.05). RESULTS The belly-press test position with resistance to elbow showed significantly greater activities of the anterior and middle deltoid muscle than the original belly-press test; but showed significantly smaller activities of pectoralis major, triceps and latissimus dorsi muscle than the original belly-press test. Among the three lift-off tests, all muscle activities, except for the pectoralis major, were greater in the lift-off at L4/5 than in the lift-off at buttock and thigh. Lift-off at thigh showed significantly smaller activity of pectoralis major than the lift-off at L4/5 and buttock. CONCLUSIONS The findings of the present study suggest that clinician should give attention to compensatory motions by excessive shoulder extensor and adductor muscle activities for the original belly press test, by excessive deltoid muscle activities for the modified belly-press, and by excessive shoulder extensor muscle activities for the lift off test in the inferior arm positions.
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Affiliation(s)
- Yu Ito
- Department of Rehabilitation, Orthopedic Hokushin Hospital, Sapporo, Japan.
| | - Hisashi Matsumoto
- Department of Rehabilitation, Orthopedic Hokushin Hospital, Sapporo, Japan
| | - Tomoya Ishida
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Shota Shimizu
- Department of Rehabilitation, Orthopedic Hokushin Hospital, Sapporo, Japan
| | - Naomi Oizumi
- Upper Extremity Center of Joint Replacement & Endoscopy, Orthopedic Hokushin Hospital, Sapporo, Japan
| | - Naoki Suenaga
- Upper Extremity Center of Joint Replacement & Endoscopy, Orthopedic Hokushin Hospital, Sapporo, Japan
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Rhee SM, Youn SM, Park JH, Chang GW, Rhee YG. The scissors sign: a provocative test for detecting the leading-edge tear of subscapularis tendon: a diagnostic study. BMC Musculoskelet Disord 2022; 23:679. [PMID: 35842588 PMCID: PMC9288008 DOI: 10.1186/s12891-022-05621-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 07/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several physical examination tests and signs have been described to aid in the diagnosis of subscapularis (SSC) tear, but have limitations and variable sensitivity. This study aimed to introduce a novel test for detecting a leading-edge tear of the subscapularis (LETS), the most important tendinous portion of SSC. METHODS A total of 233 patients who underwent arthroscopic repair for anterior and superior cuff tears between January 2018 to September 2019 were retrospectively reviewed. The provocative test we have coined as the "scissors sign" and the other related clinical tests (i.e., belly press, belly off, Napoleon, lift off, internal rotation lag, bear hug tests) were performed preoperatively. Whether the patient has a LETS or the complete tear of the SSC (CTS) was confirmed by arthroscopic findings. Sensitivity, specificity, and areas under the receiver operating characteristic curve were calculated for each test. RESULTS In patients who had LETS with or without supraspinatus tear, the scissors sign showed the highest sensitivity (91.4%) with a specificity of 81.6%, positive predictive value (PPV) of 80.2%, and negative predictive value (NPV) of 92.1%. In patients with isolated LETS, the scissors sign also showed the highest sensitivity (90.3%) with a specificity of 81.6%, PPV of 57.1%, and NPV of 96.8%. The scissors sign for the complete tear of the subscapularis (CTS) with or without supraspinatus tear and the isolated CTS had a sensitivity of 73.1 and 75%, respectively. CONCLUSIONS The scissors sign is a novel provocative test that can be helpful in the diagnosis of subscapularis tears, especially LETS, with its high sensitivity and diagnostic accuracy. In combination with other tests, the scissors sign will be a good screening tool.
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Affiliation(s)
- Sung-Min Rhee
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, Republic of Korea
| | - Seung-Min Youn
- The Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4029, Australia
| | - Joon Hong Park
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, Republic of Korea
| | - Geun Wu Chang
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, Myongji Hospital, 697-24 Hwajung-dong, Deokyang-gu, Gyeonggi-do, Goyang-si, South Korea
| | - Yong Girl Rhee
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, Myongji Hospital, 697-24 Hwajung-dong, Deokyang-gu, Gyeonggi-do, Goyang-si, South Korea.
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França FDO, Godinho GG, Freitas JMA, Lang AS, Ammar CD, Martinelli F. Correlação do exame físico com achados artroscópicos no tratamento da ruptura do manguito rotador. Rev Bras Ortop 2022; 57:467-471. [PMID: 35785111 PMCID: PMC9246533 DOI: 10.1055/s-0041-1735945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 06/02/2021] [Indexed: 11/05/2022] Open
Abstract
Objective
To compare clinical data from the physical examination with arthroscopic findings in rotator cuff rupture.
Methods
A total of 177 patients submitted to arthroscopic treatment of rotator cuff rupture were selected, and arthroscopic findings were compared with physical examination.
Results
The impingement tests showed high sensitivity for rotator cuff rupture. Among the strength tests, the most sensitive was the Patte test (85.7%), and the one with the highest positive predictive value (PPV) was the Jobe test (95%). The Drop Sign test showed higher specificity and negative predictive value (NPV) (98.7 and 95.9%, respectively). Patients with a history of trauma were 3.5 times more likely to have a positive Lift Off test.
Conclusion
The impingement tests had high sensitivity for rotator cuff ruptures. The Jobe test showed similar sensitivity among patients who had partial or total supraspinal injury. For complete lesions of the subscapularis, The Lift Off and Belly Press tests showed high sensitivity and specificity.
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Affiliation(s)
| | - Glaydson Gomes Godinho
- Serviço de Cirurgia do Ombro e Cotovelo, Hospital Ortopédico BH, Belo Horizonte, MG, Brasil
| | | | - Augusto Silveira Lang
- Especializando em Cirurgia do Ombro e Cotovelo do Hospital Ortopédico BH, Belo Horizonte, MG, Brasil
| | - Charles Diogo Ammar
- Especializando em Cirurgia do Ombro e Cotovelo do Hospital Ortopédico BH, Belo Horizonte, MG, Brasil
| | - Fabrício Martinelli
- Especializando em Cirurgia do Ombro e Cotovelo do Hospital Ortopédico BH, Belo Horizonte, MG, Brasil
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12
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Baek CH, Kim JG, Baek GR. Restoration of active internal rotation following reverse shoulder arthroplasty: anterior latissimus dorsi and teres major combined transfer. J Shoulder Elbow Surg 2022; 31:1154-1165. [PMID: 34968688 DOI: 10.1016/j.jse.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/07/2021] [Accepted: 11/16/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Reverse shoulder arthroplasty (RSA) for irreparable massive rotator cuff tear (mRCT) and cuff tear arthropathy (CTA) demonstrates satisfactory clinical outcomes. However, many studies have reported no significant improvements in internal and external rotation. To our knowledge, there have been no studies on new attempts to restore active internal rotation following RSA. The purpose of this study was to compare RSA alone and RSA with anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with CTA and mRCT with combined loss of active elevation and internal rotation (CLEIR). METHODS This retrospective cohort study included patients who underwent RSA with a lateralized design and had CLEIR between October 2014 and January 2019. Two groups were classified: patients who underwent RSA alone (group R, n = 36) and patients who underwent RSA with aLDTM tendon transfer (group T, n = 24). Clinical outcomes, including the visual analog scale score, Constant score, American Shoulder and Elbow Surgeons score, active range of motion, score for activities of daily living requiring active internal rotation (ADLIR), and ability to perform toileting activity, were compared. Moreover, radiologic outcomes and complications were compared. RESULTS The mean follow-up period was 36.8 ± 11.6 months (range, 24-67 months). Both group R and group T showed significant improvements in clinical scores and active range of motion preoperatively and postoperatively. In group T, the Constant score (65.2 ± 7.5 vs. 58.1 ± 12.3, P = .008), ADLIR score (26.1 ± 3.1 vs. 20.3 ± 5.0, P < .001), internal rotation level with the arm behind the back (P < .001), and subscapularis-specific physical examination findings (P < .001) were significantly better than in group R. However, no significant difference in the American Shoulder and Elbow Surgeons score, forward flexion, and external rotation at 0° and 90° of abduction were found at final follow-up. Transient axillary nerve palsy was found in 2 patients in group T. However, there were no significant differences in complication rates between 2 groups. CONCLUSION Lateralized RSA with aLDTM tendon transfer for patients with CTA and mRCT with CLEIR restored shoulder function and improved clinical outcomes, especially the ability to perform ADLIR and toileting activity.
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Affiliation(s)
- Chang Hee Baek
- Department of Orthopaedic Surgery, Yeosu Baek Hospital, Jeollanam-do, Republic of Korea.
| | - Jung Gon Kim
- Department of Orthopaedic Surgery, Yeosu Baek Hospital, Jeollanam-do, Republic of Korea
| | - Gyu Rim Baek
- Department of Mathematics, Dongguk University, Seoul, Republic of Korea
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13
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Subscapularis Tears: Evolution in Treatment Options. J Am Acad Orthop Surg 2022; 30:485-492. [PMID: 35294403 DOI: 10.5435/jaaos-d-21-00155] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/02/2022] [Indexed: 02/01/2023] Open
Abstract
Subscapularis tears occur more commonly than previously reported. Owing to the importance of the subscapularis in shoulder function, strong consideration should be given to repairing a full-thickness subscapularis tear when present. Historically, subscapularis repairs were done through a deltopectoral approach with good results. More recently, arthroscopic techniques have been developed with similar outcomes. When tears of the subscapularis are irreparable, reconstructive options, including tendon transfers, capsular reconstruction, and reverse shoulder arthroplasty, exist and continue to evolve.
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14
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Lädermann A, Collin P, Zbinden O, Meynard T, Saffarini M, Chiu JCH. Diagnostic Accuracy of Clinical Tests for Subscapularis Tears: A Systematic Review and Meta-analysis. Orthop J Sports Med 2022; 9:23259671211042011. [PMID: 35146034 PMCID: PMC8822023 DOI: 10.1177/23259671211042011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/09/2021] [Indexed: 12/20/2022] Open
Abstract
Background: Previous systematic reviews and meta-analyses on the diagnostic accuracy of shoulder clinical tests do not reach conclusions regarding subscapularis tears. Purpose: To compare the diagnostic accuracy of commonly used clinical tests for subscapularis tears. Study Design: Systematic review; Level of evidence, 3. Methods: An electronic literature search was conducted using Medline, Embase, and the Cochrane Library/Central. Eligibility criteria were original clinical studies reporting the diagnostic accuracy of clinical tests to diagnose the presence of rotator cuff tears involving the subscapularis. Results: The electronic literature search returned 2212 records, of which 13 articles were eligible. Among 8 tests included in the systematic review, the lift-off test was most frequently reported (12 studies). Four tests were eligible for meta-analysis: bear-hug test, belly-press test, internal rotation lag sign (IRLS), and lift-off test. The highest pooled sensitivity was 0.55 (95% CI, 0.28-0.79) for the bear-hug test, while the lowest pooled sensitivity was 0.32 (95% CI, 0.13-0.61), for the IRLS. In all tests, pooled specificity was >0.90. Conclusion: Among the 4 clinical tests eligible for meta-analysis (bear-hug test, belly-press test, IRLS, and lift-off test), all had pooled specificity >0.90 but pooled sensitivity <0.60. No single clinical test is sufficiently reliable to diagnose subscapularis tears. Registration: PROSPERO (CRD42019137019).
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Affiliation(s)
- Alexandre Lädermann
- Division of Orthopedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Orthopedics and Trauma Service, University Hospitals of Geneva, Geneva, Switzerland
| | - Philippe Collin
- Centre Hospitalier Privé Saint-Grégoire (Vivalto Santé), Saint-Grégoire, France
| | - Olivia Zbinden
- Division of Orthopedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Timon Meynard
- Division of Orthopedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | | | - Joe Chih-Hao Chiu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Taoyuan
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15
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Meder A, Stefanescu MC, Ateschrang A, Froehlich S, Obertacke U, Schulz AP, Meyerhoff HS, Oswald EJ, Sterz J, Ruesseler M. Evidence-Based Examination Techniques for the Shoulder Joint. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021; 159:332-335. [PMID: 34111895 DOI: 10.1055/a-1440-2242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Digitalisation now almost covers all areas of medical student teaching. Teaching videos are a good way to help students learn practical skills. The existing evidence is a recognised aid for the classification of the respective technology. METHOD This video presents the usual examination techniques of the shoulder joint on a patient with an unstable shoulder. The respective techniques, if available, were backed up with appropriate evidence. CONCLUSION The examination techniques presented allow students to view them in a standardized manner on a patient. The evidence for the examination techniques can help with the classification of the respective technique.
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Affiliation(s)
- Adrian Meder
- Trauma and Reconstructive Surgery, Professional Association Trauma Clinic Tübingen, Germany
| | - Maria-Christina Stefanescu
- Trauma, Hand and Reconstructive Surgery Clinic, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Atesch Ateschrang
- Orthopaedic and Trauma Surgery, Community Clinics Koblenz Mayen, Koblenz, Germany
| | - Susanne Froehlich
- Orthopaedic Clinic and Polyclinic, University Clinics Rostock, Rostock, Germany
| | - Udo Obertacke
- Orthopaedic and Trauma Surgery Centre, University Clinics Mannheim, Germany
| | - Arndt Peter Schulz
- Clinic for Surgery of the Musculoskeletal and Locomotor System of Lübeck University, Lübeck, Germany.,Trauma Surgery and Orthopaedics, Professional Association Trauma Hospital Hamburg, Germany
| | | | - Eva J Oswald
- Media Competence Centre, Eberhard Karl University of Tübingen, Tübingen, Germany
| | - Jasmina Sterz
- Trauma, Hand and Reconstructive Surgery Clinic, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Miriam Ruesseler
- Trauma, Hand and Reconstructive Surgery Clinic, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
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16
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Evaluating subscapularis tendon tears on axillary lateral radiographs using deep learning. Eur Radiol 2021; 31:9408-9417. [PMID: 34014379 DOI: 10.1007/s00330-021-08034-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/06/2021] [Accepted: 04/30/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To develop a deep learning algorithm capable of evaluating subscapularis tendon (SSC) tears based on axillary lateral shoulder radiography. METHODS A total of 2,779 axillary lateral shoulder radiographs (performed between February 2010 and December 2018) and the patients' corresponding clinical information (age, sex, dominant side, history of trauma, and degree of pain) were used to develop the deep learning algorithm. The radiographs were labeled based on arthroscopic findings, with the output being the probability of an SSC tear exceeding 50% of the tendon's thickness. The algorithm's performance was evaluated by determining the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, negative predictive value (NPV), and negative likelihood ratio (LR-) at a predefined high-sensitivity cutoff point. Two different test sets were used, with radiographs obtained between January and December 2019; Test Set 1 used arthroscopic findings as the reference standard (n = 340), whereas Test Set 2 used MRI findings as the reference standard (n = 627). RESULTS The AUCs were 0.83 (95% confidence interval, 0.79-0.88) and 0.82 (95% confidence interval, 0.79-0.86) for Test Sets 1 and 2, respectively. At the high-sensitivity cutoff point, the sensitivity, NPV, and LR- were 91.4%, 90.4%, and 0.21 in Test Set 1, and 90.2%, 89.5%, and 0.21 in Test Set 2, respectively. Gradient-weighted Class Activation Mapping identified the subscapularis insertion site at the lesser tuberosity as the most sensitive region. CONCLUSION Our deep learning algorithm is capable of assessing SSC tears based on changes at the lesser tuberosity on axillary lateral radiographs with moderate accuracy. KEY POINTS • We have developed a deep learning algorithm capable of assessing SSC tears based on changes at the lesser tuberosity on axillary lateral radiographs and previous clinical data with moderate accuracy. • Our deep learning algorithm could be used as an objective method to initially assess SSC integrity and to identify those who would and would not benefit from further investigation or treatment.
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17
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Nové-Josserand L, Chauvet T, Baudin F, Godenèche A, Collotte P, Vieira TD, Haritinian E. Subcapularis tendon tear: A structure-based arthroscopic description. Orthop Traumatol Surg Res 2021; 107:102757. [PMID: 33316451 DOI: 10.1016/j.otsr.2020.102757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/09/2020] [Accepted: 07/06/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Subscapularis (SSC) tendons differ from supraspinatus tendons, although both have similar histologic structure comprising two layers with distinct collagen fiber organization. HYPOTHESIS The partial/full-thickness tear classification for the supraspinatus based on tendon structure can be applied to the subscapularis tendon on objective criteria. MATERIAL AND METHODS The present study used 100 films of arthroscopic rotator cuff repair involving SSC lesion. Lesions were reported on 3 objective criteria: horizontal superior tendon edge visibility, lesser tuberosity bone exposure, and lateral tendon edge visibility. Combining the three distinguishes deep, superficial or interstitial partial tear versus full-thickness tear. Degree of retraction was also noted. RESULTS Forty-six of the 73 partial lesions involved the deep articular layer, which was often retracted, but conserving the horizontal superior tendon edge and thus misleadingly suggesting SSC integrity; 23 were interstitial, without detachment from the lesser tuberosity; 4 involved only the superficial layer. Full-thickness tears were always retracted, with loss of horizontal superior tendon edge, visibility of the lateral tendon edge and presence of comma sign. Inter- and intra-observer reproducibility was satisfactory. DISCUSSION - CONCLUSION Like in superior cuff tear, a structure-based classification can be made of SSC lesions on objective criteria. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Laurent Nové-Josserand
- Unité épaule, Ramsay générale de santé, centre orthopédique Santy, hôpital privé Jean-Mermoz, 24, avenue Paul-Santy, 69008 Lyon, France.
| | - Thomas Chauvet
- Unité épaule, Ramsay générale de santé, centre orthopédique Santy, hôpital privé Jean-Mermoz, 24, avenue Paul-Santy, 69008 Lyon, France
| | - Florian Baudin
- Dijon university hospital, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - Arnaud Godenèche
- Unité épaule, Ramsay générale de santé, centre orthopédique Santy, hôpital privé Jean-Mermoz, 24, avenue Paul-Santy, 69008 Lyon, France
| | - Philippe Collotte
- Unité épaule, Ramsay générale de santé, centre orthopédique Santy, hôpital privé Jean-Mermoz, 24, avenue Paul-Santy, 69008 Lyon, France
| | - Thais Dutra Vieira
- Unité épaule, Ramsay générale de santé, centre orthopédique Santy, hôpital privé Jean-Mermoz, 24, avenue Paul-Santy, 69008 Lyon, France
| | - Emil Haritinian
- Carol Davila university of medicine and pharmacy, Foișor orthopaedic hospital, 35-37, Ferdinand I, 021382 Bucharest, Romania
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18
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Dakkak A, Krill MK, Krill ML, Nwachukwu B, McCormick F. Evidence-Based Physical Examination for the Diagnosis of Subscapularis Tears: A Systematic Review. Sports Health 2020; 13:78-84. [PMID: 32822265 DOI: 10.1177/1941738120936232] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
CONTEXT There is a renewed interest in diagnosing and treating subscapularis tears, but there is a paucity of clinical guidance to optimize diagnostic decision-making. OBJECTIVE To perform a literature review to evaluate advanced maneuvers and special tests in the diagnosis of subscapularis tears and create a diagnostic algorithm for subscapularis pathology. DATA SOURCES PubMed, MEDLINE, Ovid, and Cochrane Reviews databases. STUDY SELECTION Inclusion criteria consisted of level 1 and 2 studies published in peer-reviewed scientific journals that focused on physical examination. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 2. DATA EXTRACTION Individual test characteristics (bear hug, belly press, lift-off, Napoleon, and internal rotation lag sign) were combined in series and in parallel to maximize clinical sensitivity and specificity for any special test evaluated in at least 2 studies. A secondary analysis utilized subjective pretest probabilities to create a clinical decision tree algorithm and provide posttest probabilities. RESULTS A total of 3174 studies were identified, and 5 studies met inclusion criteria. The special test combination of the bear hug and belly press demonstrated the highest positive likelihood ratio (18.29). Overall, 3 special test combinations in series demonstrated a significant impact on posttest probabilities. With parallel testing, the combination of bear hug and belly press had the highest sensitivity (84%) and lowest calculated negative likelihood ratio (0.21). CONCLUSION The combined application of the bear hug and belly press physical examination maneuvers is an optimal combination for evaluating subscapularis pathology. Positive findings using this test combination in series with a likely pretest probability yield a 96% posttest probability; whereas, negative findings tested in parallel with an unlikely pretest probability yield a 12% posttest probability.
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Affiliation(s)
- Andrew Dakkak
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Michael K Krill
- Division of Neurorehabilitation, Department of Neurology, Washington University in St Louis, St Louis, Missouri
| | - Matthew L Krill
- Jameson Crane Sports Medicine Institute, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Benedict Nwachukwu
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Frank McCormick
- Department of Orthopedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Sports Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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19
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Lapner P, Pollock JW, Zhang T, Ruggiero S, Momoli F, Sheikh A, Athwal GS. A randomized controlled trial comparing subscapularis tenotomy with peel in anatomic shoulder arthroplasty. J Shoulder Elbow Surg 2020; 29:225-234. [PMID: 31780337 DOI: 10.1016/j.jse.2019.09.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Controversy exists regarding the optimal technique of subscapularis tendon mobilization during anatomic shoulder arthroplasty. The purpose of this prospective, randomized, double-blind study was to compare internal rotation strength in the belly-press position and functional outcomes between the subscapularis tenotomy and subscapularis peel approaches during shoulder arthroplasty. METHODS Patients undergoing anatomic shoulder arthroplasty were randomized to either a tenotomy or peel approach. The primary outcome was internal rotation strength in the belly-press position, measured by an electronic handheld dynamometer at 24 months postoperatively. Secondary outcomes included the Western Ontario Osteoarthritis of the Shoulder (WOOS) index score, American Shoulder and Elbow Surgeons (ASES) score, range of motion, radiographic lucencies, and adverse events. RESULTS We randomized 100 patients to subscapularis tenotomy (n = 47) or peel (n = 53). Eighty-one percent of the cohort returned for 24 months' follow-up. Compared with baseline measures, mean internal rotation strength in the belly-press position and WOOS and ASES scores improved in both groups at final follow-up (P < .0001). Intention-to-treat analysis for internal rotation strength at 24 months revealed no significant difference (P = .57) between tenotomy (mean, 4.9 kg; SD, 3.8 kg) and peel (mean, 5.4 kg; SD, 3.9 kg). Comparison of WOOS and ASES scores demonstrated no significant differences between groups at any time point. The healing rates by ultrasound were 72% for tenotomy and 71% for peel (P = .99). DISCUSSION No statistically significant difference in internal rotation strength was identified between the tenotomy and peel groups. The secondary outcomes were not significantly different between groups.
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Affiliation(s)
- Peter Lapner
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - J Whitcomb Pollock
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Tinghua Zhang
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sara Ruggiero
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Franco Momoli
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Adnan Sheikh
- Department of Medical Imaging, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - George S Athwal
- Roth
- McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care London, London, ON, Canada; University of Western Ontario, London, ON, Canada
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20
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A Comprehensive Review of Physical Examination Tests of the Cervical Spine, Scapula, and Rotator Cuff. J Am Acad Orthop Surg 2019; 27:385-394. [PMID: 30383577 DOI: 10.5435/jaaos-d-17-00090] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
A thorough physical examination of the shoulder and cervical spine is critical in establishing a focused differential diagnosis of the pathology in and around the shoulder joint. Numerous tests have been described in the literature to help improve the diagnostic accuracy of specific shoulder or cervical spine pathology. A comprehensive approach for the physical examination of the cervical spine, scapula, and rotator cuff is presented and descriptions on how the tests are performed and the evidence behind why specific tests are used in enabling improved diagnosis of shoulder pathology are discussed.
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21
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Cotter EJ, Hannon CP, Christian D, Frank RM, Bach BR. Comprehensive Examination of the Athlete's Shoulder. Sports Health 2018; 10:366-375. [PMID: 29443643 PMCID: PMC6044121 DOI: 10.1177/1941738118757197] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Context: Shoulder pain and dysfunction are common, with patients presenting complaints
to both primary and orthopaedic physicians. History and physical examination
remain essential to creating a differential diagnosis, even as noninvasive
imaging has improved. Evidence Acquisition: Literature was obtained through keyword searches based on the pathology in
question (eg, rotator cuff) and the keywords physical
examination using PubMed from January 1, 1980, through
September 20, 2017. Additional evidence was obtained through screening
references from articles identified through the PubMed searches. Study Design: Clinical review. Level of Evidence: Level 3. Results: A total of 7817 articles were screened for relevance. Several physical
examination maneuvers have been described for each specific pathology. The
Neer sign has a 75% sensitivity for subacromial impingement (SAI), while the
Hawkins-Kennedy test has an 80% sensitivity. The painful arc test has an 80%
specificity for SAI. The apprehension test has a hazard ratio of 2.96 for
anterior shoulder instability. The Jobe test has a sensitivity of 52.6% and
a specificity of 82.4% for full-thickness supraspinatus tears, confirmed on
arthroscopy. The lag sign is highly sensitive and specific for combined
full-thickness supraspinatus and infraspinatus tears at 97% and 93%,
respectively. The Speed test has a sensitivity of 54% and specificity of 81%
for biceps pathology. The anterior slide test and O’Brien active compression
test have been described for superior labrum anterior posterior tears with
inconsistent reliability. The cross-body adduction test has a sensitivity of
77% and a specificity of 79% for acromioclavicular joint pathology. Conclusion: Several physical examination maneuvers can isolate specific pathology of the
shoulder, with widely ranging sensitivity and specificity.
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Affiliation(s)
- Eric J Cotter
- Section of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Charles P Hannon
- Section of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - David Christian
- Section of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Rachel M Frank
- Section of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Bernard R Bach
- Section of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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22
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Kappe T, Sgroi M, Reichel H, Daexle M. Diagnostic performance of clinical tests for subscapularis tendon tears. Knee Surg Sports Traumatol Arthrosc 2018; 26:176-181. [PMID: 28676889 DOI: 10.1007/s00167-017-4617-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/19/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Tears of the subscapularis (SSC) tendon constitute a diagnostic challenge. The purpose of the present study was to evaluate the diagnostic capabilities of five clinical SSC tests. METHODS Five established clinical tests were evaluated in 106 consecutive patients prior to shoulder arthroscopy. The tests included the Lift Off Test, Internal Rotation Lag Sign, Belly Press Test, Belly Off Sign, and Bear Hug Test. The integrity of the SSC tendon at surgery was used as the gold standard. Lesions to the SSC were graded according to Fox and Romeo. RESULTS There were 32 SSC lesions accounting for an incidence of 30.2%. The sensitivity for all tests was 0.66, while the specificity was 0.82. For all tests, positive tests results were found to be dependent on subscapularis integrity (p < 0.001, respectively). The sensitivity for any type of SSC lesion for the Lift Off Test, Internal Rotation Lag Sign, Belly Press Test, Belly Off Sign, and Bear Hug Test was 0.35, 0.41, 0.34, 0.31, and 0.52, respectively. Specificity was found to be 0.98, 0.91, 0.96, 0.97, and 0.85, respectively. If only grade 2-4 tears were analysed, sensitivity was 0.32, 0.42, 0.37, 0.37, and 0.72 and specificity 0.94, 0.86, 0.92, 0.94, and 0.84. A positive correlation was found between the number of positive tests and the severity of the SSC lesions. CONCLUSION In the present study, the Bear Hug Test was found to have the highest sensitivity of all tests studied, especially for tears of the upper tendon border. It appears advisable to perform more than one clinical subscapularis test to further improve sensitivity. Nevertheless, SSC tears may still escape clinical recognition. Therefore, a high index of suspicion has to be maintained in order not to miss SSC tears. LEVEL OF EVIDENCE Diagnostic study, Level I.
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Affiliation(s)
- Thomas Kappe
- Department for Orthopaedic Surgery, RKU, University of Ulm, Ulm, Germany.
| | - Mirco Sgroi
- Department for Orthopaedic Surgery, RKU, University of Ulm, Ulm, Germany
| | - Heiko Reichel
- Department for Orthopaedic Surgery, RKU, University of Ulm, Ulm, Germany
| | - Manuel Daexle
- Department for Orthopaedic Surgery, RKU, University of Ulm, Ulm, Germany
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Visonà E, Vio S, Franceschi G, Maron A, Corona K, Cerciello S, Merolla G, Berizzi A, Aldegheri R. Orthopedic resident's learning curve for arthroscopic subscapularis tendon repair: short-term clinical and radiographic outcomes. Musculoskelet Surg 2017; 101:145-151. [PMID: 28756508 DOI: 10.1007/s12306-017-0485-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 06/08/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Arthroscopic subscapularis (SSC) repair is a technically demanding procedure with a long learning curve. As effective completion of resident's practical experience remains controversial, a prospective clinical study was performed to assess the functional and anatomical outcomes of subscapularis (SSC) arthroscopic repair by orthopedic residents. The pathological anatomy of the tears, the surgical approach and the difficulties encountered at the beginning of the learning curve were reported. MATERIALS AND METHODS Between June 2009 and June 2010, 30 patients with rotator cuff tear were preoperatively evaluated with clinical exam, Constant and UCLA scores. Surgery was performed under arthroscopy by a team of three orthopedic surgeons in training. A SSC tear, if present, was recorded and treated. The same clinical exam and functional scores were repeated at minimum 6 months of follow-up. Subscapularis strength recovery and tendon healing were investigated with arthromagnetic resonance imaging. RESULTS A SSC tear was observed in 11 cases out of 30 and treated arthroscopically. The clinical scores improved in all patients: the average Constant score increased from 34 ± 14 to 77 ± 11 and the UCLA score from 11 ± 5 to 29 ± 3. The SSC tests were negative in all patients with the exception of one. Tendon healing was observed in 10 out of 11 cases. CONCLUSIONS Arthroscopic SSC repair performed by educated residents is possible and leads to good clinical and anatomical results. Surgery duration progressively improved as the learning curve advanced. LEVEL OF EVIDENCE Level 2.
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Affiliation(s)
- E Visonà
- Clinica Ortopedica, Università degli Studi di Padova, Via Giustiniani 2, Padua, Italy.
- Ospedali Riuniti Padova Sud - ULSS 6 EUGANEA, Via Albere 30, Schiavonia, PD, Italy.
| | - S Vio
- Radiologia I, Ospedale di Padova, Via Giustiniani 2, Padua, Italy
| | - G Franceschi
- Clinica Ortopedica, Università degli Studi di Padova, Via Giustiniani 2, Padua, Italy
- Policlinico Abano Terme, Piazza C. Colombo 1, Abano Terme, Padova, Italy
| | - A Maron
- Clinica Ortopedica, Università degli Studi di Padova, Via Giustiniani 2, Padua, Italy
- Ospedali Riuniti Padova Sud - ULSS 6 EUGANEA, Via Albere 30, Schiavonia, PD, Italy
| | - K Corona
- Dipartimento di Scienza per la Salute, Università del Molise, Via De Sanctis, 86100, Campobasso, Italy
| | - S Cerciello
- Casa di Cura Villa Betania, Via Piccolomini 27, 00165, Rome, Italy
- Marrelli Hospital, Via Gioacchino da Fiore, 0962, Crotone, Italy
| | - G Merolla
- Unità di Chirurgia della Spalla e del Gomito, Ospedale D. Cervesi, Cattolica, RN, Italy
| | - A Berizzi
- Clinica Ortopedica, Università degli Studi di Padova, Via Giustiniani 2, Padua, Italy
| | - R Aldegheri
- Clinica Ortopedica, Università degli Studi di Padova, Via Giustiniani 2, Padua, Italy
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Abstract
BACKGROUND In the current literature a consensus on the specific management of primary anterior traumatic shoulder instability has not been reached. While the steps of the initial diagnostic and therapeutic procedures are mostly well-defined, a variety of factors need to be considered for the planning of further treatment. OBJECTIVE This article aims at giving an overview of the essential aspects of the initial management in the rescue center, clinical and radiological diagnostic procedures and the subsequent treatment options. MATERIAL AND METHODS The content of this article is based on our own clinical experiences in combination with a systematic literature search for relevant clinical and baseline studies. RESULTS Besides a detailed anamnesis and clinical examination, X‑rays in two planes are important for the diagnosis. Potential nerve injuries or fractures need to be borne in mind before and after reduction of the joint and documented accordingly. The Matsen's maneuver can be recommended as it enables a careful repositioning. In rare cases of an irreducible shoulder dislocation due to soft tissue or bony articular interpositions, an open reduction might be necessary. Further therapeutic concepts should be adapted to patient age, activity level and accompanying pathologies, which determine the risk of a recurrent dislocation. A surgical approach for stabilization of the shoulder is highly recommended in cases of concomitant bony defects as well as in young and physically active patients. CONCLUSION A well-structured treatment plan is essential for the initial management of primary anterior traumatic shoulder instability. A generally applicable algorithm for further management is not yet established. The treatment should therefore be individually planned based on patient-specific characteristics.
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Saulle M, Gellhorn AC. Approach to the diagnosis of shoulder pain using physical exam and ultrasound: an evidence-based approach. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2017. [DOI: 10.1007/s40141-017-0149-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Ono Y, Sakai T, Carroll MJ, Lo IK. Tears of the Subscapularis Tendon. JBJS Rev 2017; 5:01874474-201703000-00001. [DOI: 10.2106/jbjs.rvw.16.00054] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Diagnostic Value of the Supine Napoleon Test for Subscapularis Tendon Lesions. Arthroscopy 2016; 32:2459-2465. [PMID: 27349714 DOI: 10.1016/j.arthro.2016.04.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 04/21/2016] [Accepted: 04/22/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare the diagnostic value of the supine Napoleon test (a variation of the belly-press test that reduces compensatory motion) with other clinical tests for subscapularis tendon (SSC) tears. METHODS One hundred thirty consecutive patients who were scheduled for arthroscopic rotator cuff repair were evaluated preoperatively with the lift-off test, Napoleon test, bear-hug test, and supine Napoleon test. The supine Napoleon test was performed by placing the patient's hand on their belly while they lay supine with an examiner holding their hand and shoulder to prevent compensatory motion. The patient was asked to move their elbow upward and the test was considered positive if they were unable to do so. During surgery, SSC lesions were classified with the Lafosse classification system. Sensitivity, specificity, accuracy, and positive and negative likelihood ratios (LR+, LR-) were calculated for each test. The ability to detect partial SSC tears was compared among the clinical tests. RESULTS Fifty-two of 130 patients (40%) had SSC tears confirmed arthroscopically. For diagnosis of these tears, the supine Napoleon test was the most sensitive (84%), followed by the bear-hug test (74%), and the bear-hug test was the most specific (97%), followed by the supine Napoleon test (96%). The LR+ was greatest for the bear-hug test (28.4) and next greatest for the supine Napoleon test (21.9). The LR- was lowest for the supine Napoleon test (0.16) and the bear-hug test was second (0.27). The sensitivity of the supine Napoleon test (65%) was highest for detecting partial tears. CONCLUSIONS In comparison with other clinical tests for SSC tears, the supine Napoleon test had the greatest diagnostic value for full-thickness SSC tears and was most able to detect partial tears. LEVEL OF EVIDENCE Level III, diagnostic nonrandomized study.
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Carreño Mesa FA, Osma Rueda JL. Diagnóstico de la rotura del manguito de los rotadores (pruebas clínicas e imagenología). Revisión de conceptos actuales. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.rccot.2016.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Moulton SG, Greenspoon JA, Millett PJ, Petri M. Risk Factors, Pathobiomechanics and Physical Examination of Rotator Cuff Tears. Open Orthop J 2016; 10:277-285. [PMID: 27708731 PMCID: PMC5039902 DOI: 10.2174/1874325001610010277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 07/21/2015] [Accepted: 02/01/2016] [Indexed: 12/31/2022] Open
Abstract
Background: It is important to appreciate the risk factors for the development of rotator cuff tears and specific physical examination maneuvers. Methods: A selective literature search was performed. Results: Numerous well-designed studies have demonstrated that common risk factors include age, occupation, and anatomic considerations such as the critical shoulder angle. Recently, research has also reported a genetic component as well. The rotator cuff axially compresses the humeral head in the glenohumeral joint and provides rotational motion and abduction. Forces are grouped into coronal and axial force couples. Rotator cuff tears are thought to occur when the force couples become imbalanced. Conclusion: Physical examination is essential to determining whether a patient has an anterosuperior or posterosuperior tear. Diagnostic accuracy increases when combining a series of examination maneuvers.
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Affiliation(s)
- Samuel G Moulton
- Steadman Philippon Research Institute 181 West Meadow Drive, Suite 1000 Vail, CO, 81657, USA
| | - Joshua A Greenspoon
- Steadman Philippon Research Institute 181 West Meadow Drive, Suite 1000 Vail, CO, 81657, USA
| | - Peter J Millett
- Steadman Philippon Research Institute 181 West Meadow Drive, Suite 1000 Vail, CO, 81657, USA; The Steadman Clinic, 181 West Meadow Drive Vail, CO, 81657, USA
| | - Maximilian Petri
- Steadman Philippon Research Institute 181 West Meadow Drive, Suite 1000 Vail, CO, 81657, USA; The Steadman Clinic, 181 West Meadow Drive Vail, CO, 81657, USA
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Jang HS, Kong DH, Jang SH. Correlation between Subscapularis Tears and the Outcomes of Physical Tests and Isokinetic Muscle Strength Tests. Clin Shoulder Elb 2016. [DOI: 10.5397/cise.2016.19.2.90] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Banerjee M, Müller-Hübenthal J, Grimme S, Balke M, Bouillon B, Lefering R, Goßmann A, Shafizadeh S. Moderate value of non-contrast magnetic resonance imaging after non-dislocating shoulder trauma. Knee Surg Sports Traumatol Arthrosc 2016; 24:1888-95. [PMID: 24923686 DOI: 10.1007/s00167-014-3102-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Accepted: 05/27/2014] [Indexed: 01/02/2023]
Abstract
PURPOSE The purpose of the present study was to determine the value of shoulder magnetic resonance imaging (MRI) obtained in the community setting interpreted by musculoskeletal radiologists in patients with shoulder pain initiated by a single non-dislocating shoulder trauma. METHODS In 56 of 61 consecutive patients who underwent shoulder arthroscopy due to pain after a single non-dislocating shoulder trauma, the data sets of non-contrast MRI were complete. These were retrospectively interpreted by three radiologists specialized on musculoskeletal MRI who were blinded for patients' history and who did not have access to the reports of arthroscopy. Standard evaluation forms were used to assess the MRIs for superior labrum anterior and posterior (SLAP) lesions, anterior or posterior labrum lesions, lesions of the long head of biceps tendon (LHB) and for partial tears of the supraspinatus tendon and the upper quarter of the subscapularis tendon. Quality of the MRI was assessed by each radiologist on a four-point scale. RESULTS The pooled sensitivity for the three radiologists for the detection of SLAP lesions was 45.0 %, for anterior or posterior labrum tears 77.8 and 66.7 %, for lesions of the LHB 63.2 % and for partial tears of the supraspinatus or subscapularis tendon tears 84.8 and 33.3 %. Corresponding inter-rater reliabilities were poor (SLAP lesions) to substantial (anterior labrum tears). Quality of MRI only influenced the accuracy for the detection of posterior labrum tears. CONCLUSION A non-contrast shoulder MRI obtained in the community setting after non-dislocating shoulder trauma has a moderate sensitivity for most intraarticular pathologies when interpreted by musculoskeletal radiologists. Accuracy is dependent on the observer and not on the assessed quality. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Marc Banerjee
- Department of Orthopedic and Trauma Surgery, Faculty of Health - School of Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Ostmerheimerstr. 200, 51109, Cologne, Germany.
| | | | | | - Maurice Balke
- Department of Orthopedic and Trauma Surgery, Faculty of Health - School of Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Ostmerheimerstr. 200, 51109, Cologne, Germany
| | - Bertil Bouillon
- Department of Orthopedic and Trauma Surgery, Faculty of Health - School of Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Ostmerheimerstr. 200, 51109, Cologne, Germany
| | - Rolf Lefering
- Cologne Merheim Medical Center, IFOM, Institute for Research in Operative Medicine, University of Witten/Herdecke, Cologne, Germany
| | - Axel Goßmann
- Department of Radiology, Cologne Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | - Sven Shafizadeh
- Department of Orthopedic and Trauma Surgery, Faculty of Health - School of Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Ostmerheimerstr. 200, 51109, Cologne, Germany
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Chalmers PN, Cvetanovich GL, Kupfer N, Wimmer MA, Verma NN, Cole BJ, Romeo AA, Nicholson GP. The champagne toast position isolates the supraspinatus better than the Jobe test: an electromyographic study of shoulder physical examination tests. J Shoulder Elbow Surg 2016; 25:322-9. [PMID: 26443105 DOI: 10.1016/j.jse.2015.07.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/25/2015] [Accepted: 07/30/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND While Jobe's test is widely used, it does not isolate supraspinatus activity. Our purpose was to examine the electromyographic (EMG) activity within the supraspinatus and deltoid with resisted abduction to determine the shoulder position that best isolates the activity of the supraspinatus. METHODS We performed EMG analysis of the supraspinatus, anterior head of the deltoid, and middle head of the deltoid in 10 normal volunteers. We measured EMG activity during resisted shoulder abduction in the scapular plane to both manual resistance and a standardized load in varying degrees of abduction and rotation. To determine which position best isolates supraspinatus activity, the ratio of supraspinatus to deltoid activity (S:D) was calculated for each position. Results were analyzed with a repeated-measures analysis of variance with Bonferroni correction. The posterior deltoid was excluded as it serves mostly to extend and externally rotate. RESULTS Our study confirmed Jobe's findings of maximal supraspinatus activity at 90° of abduction. However, decreasing abduction significantly increased S:D for both resisted manual testing and testing against a standardized load (P = .002 and .001, respectively). The greatest S:D ratio (4.6 ± 3.4 for standardized load testing) was seen at the "champagne toast" position, i.e., 30° of abduction, mild external rotation, 30° of flexion, and 90° of elbow flexion. The smallest ratio (0.8 ± 0.6) was seen at Jobe's position. CONCLUSIONS Testing of abduction strength in the champagne toast position, i.e., 30° of abduction, mild external rotation, and 30° of flexion, better isolates the activity of the supraspinatus from the deltoid than Jobe's "empty can" position.
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Affiliation(s)
- Peter N Chalmers
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
| | | | - Noam Kupfer
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Markus A Wimmer
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Brian J Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Anthony A Romeo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Internal rotation resistance test at abduction and external rotation: a new clinical test for diagnosing subscapularis lesions. Knee Surg Sports Traumatol Arthrosc 2015; 23:1247-52. [PMID: 24337464 DOI: 10.1007/s00167-013-2808-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 11/30/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE A new clinical test for evaluating subscapularis (SSC) integrity was described, and its diagnostic value was compared with the present SSC tests (the lift-off, belly-press, IRLS and bear-hug tests). The new test is called internal rotation resistance test at abduction and external rotation (IRRT). The test is performed at maximal 90° of abduction and maximal external rotation. METHODS Two hundred and thirty-five consecutive patients suffering from rotator cuff injury were evaluated preoperatively. Six tests were performed to assess the function of the SSC: the lift-off, belly-press, IRLS, the bear-hug, IRRT at 0° abduction and 0° external rotation (IRRT0°) and IRRT at maximal 90° abduction and maximal external rotation (IRRTM). Arthroscopic findings were the reference for diagnosing of SSC lesions. RESULTS The IRRTM test showed the greatest sensitivity (76.5 %), and IRLS (31.6 %) test had the lowest sensitivity. The IRRTM had the highest accuracy (79.0 %), and lift-off had the lowest accuracy (65.3 %). Positive IRRTM, bear-hug, belly-press, IRRT0° tests indicate that about one-third of the SSC is torn, and a positive lift-off and IRLS tests predict a severe tear at least two-thirds of the SSC. CONCLUSIONS The IRRTM represents a sensitive diagnostic test for SSC lesions and improves the chance of finding the upper part of the SSC tears. When the IRRTM is positive, the surgeon should pay particular attention to detecting the SSC tendon during arthroscopy. LEVEL OF EVIDENCE Diagnostic study, Level I.
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Pandey T, Slaughter AJ, Reynolds KA, Jambhekar K, David RM, Hasan SA. Clinical orthopedic examination findings in the upper extremity: correlation with imaging studies and diagnostic efficacy. Radiographics 2015; 34:e24-40. [PMID: 24617698 DOI: 10.1148/rg.342125061] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Different orthopedic tests are used to evaluate internal derangements of joints. Radiologic examinations like magnetic resonance (MR) imaging are ordered on the basis of results of these tests to narrow the clinical diagnosis and formulate a treatment plan. Although these tests are clinically useful, the test terminology can be confusing and the significance of the tests not clearly understood. This article helps explain the clinical jargon of tests performed for the major joints of the upper extremity and their proper use and diagnostic value in conjunction with MR imaging. The article presents a structured algorithmic approach to explain the tests. For each joint, a hierarchy of clinical tests is performed, starting with general observation and range of motion, followed by more specific tests tailored to evaluate individual or grouped anatomic structures. MR imaging findings and clinical tests complement each other in making a final diagnosis. However, because of the varied sensitivity and specificity of the clinical tests and MR imaging, it is important to be familiar with their diagnostic value before making clinical decisions. Knowledge of clinical jargon and the proper use and diagnostic value of orthopedic tests can aid in interpretation of radiologic images by focusing search patterns, thus allowing comprehensive evaluation and optimized reporting. It also enhances communication with the orthopedist, thereby helping maintain continuity of care. Online supplemental material is available for this article.
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Affiliation(s)
- Tarun Pandey
- From the Department of Radiology, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR 72205 (T.P., A.J.S., K.J., R.M.D.); Department of Orthopaedic Surgery, University of Colorado, Boulder, Colo (K.A.R.); and Department of Orthopaedics, University of Maryland Medical Center, Baltimore, Md (S.A.H.)
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Buckley T, Miller R, Nicandri G, Lewis R, Voloshin I. Analysis of subscapularis integrity and function after lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty using ultrasound and validated clinical outcome measures. J Shoulder Elbow Surg 2014; 23:1309-17. [PMID: 24618191 DOI: 10.1016/j.jse.2013.12.009] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 11/26/2013] [Accepted: 12/03/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND The optimal method-subscapularis peel (SP) or lesser tuberosity osteotomy (LTO)-for takedown of the subscapularis during total shoulder arthroplasty (TSA) is controversial. This study compares the functional outcomes in a 2-surgeon cohort using the 2 techniques. METHODS Patients who underwent TSA with a minimum 1 year of follow-up were evaluated. Physical and ultrasound examinations of the operative shoulder were performed. Radiographs were evaluated for osteotomy healing. Patients completed the Western Ontario Osteoarthritis of the Shoulder (WOOS) index, Disability of the Arm, Shoulder, and Hand (DASH), and Constant Scores. RESULTS Subscapularis tenotomy (n = 32) and LTO (n = 28) patients were similar in age, hand dominance, and sex. Follow-up duration for subscapularis tenotomy and LTO patients differed (31.7 vs 22.1 months, P = .003). SP patients demonstrated increased external rotation (69° ± 12° vs 60° ± 11°). Belly press and bear hug resistance were not significantly different. WOOS (P = .13), DASH (P = .71), and Constant Scores (P = .80) were not significantly different. After controlling for follow-up imbalance, the WOOS score difference was statistically significant (91.5 ± 10.2 for LTO vs 82.1 ± 18.9 for SP, P = .05) but not clinically significant. By ultrasonography assessment, 4 subscapularis tendons were abnormal in the SP group (3 attenuated, 1 ruptured), and all tendons were normal in the LTO group. Patients with an abnormal ultrasound result had significantly inferior WOOS (88 ± 15 vs 65 ± 18) and DASH (11.5 ± 11.4 vs 25.9 ± 11.2) scores. Belly press resistance was significantly decreased, bear hug resistance trended lower, and external rotation was increased in the abnormal ultrasound group. CONCLUSIONS Abnormal subscapularis tendons identified by ultrasonography only in the SP group correlate with clinically significant inferior functional outcome scores.
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Affiliation(s)
- Taylor Buckley
- Department of Orthopaedics & Rehabilitation, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA
| | - Richard Miller
- Department of Orthopaedics & Rehabilitation, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA
| | - Gregg Nicandri
- Department of Orthopaedics & Rehabilitation, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA
| | - Richard Lewis
- Department of Orthopaedics & Rehabilitation, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA
| | - Ilya Voloshin
- Department of Orthopaedics & Rehabilitation, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA.
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Yoon JP, Chung SW, Kim SH, Oh JH. Diagnostic value of four clinical tests for the evaluation of subscapularis integrity. J Shoulder Elbow Surg 2013; 22:1186-92. [PMID: 23434234 DOI: 10.1016/j.jse.2012.12.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 11/21/2012] [Accepted: 12/02/2012] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The lift-off, internal rotation lag sign, belly-press, and bear-hug tests are widely used to evaluate the integrity of the subscapularis. We hypothesized that these tests might reflect different types of subscapularis tears and sought to ascertain whether these tests accurately determine the severity of the internal rotation strength deficit and fatty degeneration. METHODS Isokinetic testing and the 4 clinical tests were used preoperatively to evaluate 312 patients who had undergone arthroscopic rotator cuff surgery. Of these, 37 patients had a full-thickness subscapularis tear, 96 had a partial-thickness tear, and 179 had no tear. RESULTS For differentiating any tears from an intact subscapularis, the most sensitive test was the belly-press test (27.8%), and the most specific test was the lift-off test (100%). For differentiating a full-thickness tear from a partial tear, the most sensitive test was the belly-press test (56.8%), and the most specific was the lift-off test (96.9%). A positive lift-off test also most reflected loss of internal rotation strength (mean, 72.2%; 95% confidence interval, 61.9-82.5), followed by the internal rotation lag sign (55.1%; 44.2-66.1) and the belly-press test (45.9%; 36.4-54.4). CONCLUSIONS A positive lift-off test was highly specific for the detection of a full-thickness subscapularis tear and to reflect severe fatty degeneration. The lift-off, internal rotation lag sign, belly-press, and bear-hug tests sequentially predict internal rotation strength deficit and provide discrimination of internal rotation strength impairment.
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Affiliation(s)
- Jong Pil Yoon
- Department of Orthopedic Surgery, Kyungpook National University School of Medicine, Daegu, South Korea
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Jain NB, Wilcox RB, Katz JN, Higgins LD. Clinical examination of the rotator cuff. PM R 2013; 5:45-56. [PMID: 23332909 DOI: 10.1016/j.pmrj.2012.08.019] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 08/09/2012] [Accepted: 08/14/2012] [Indexed: 11/28/2022]
Abstract
Rotator cuff tears are the leading cause of shoulder pain and shoulder-related disability and account for 4.5 million physician visits in the United States annually. A careful history and structured physical examination are often sufficient for diagnosing rotator cuff disorders. We are not aware of a clinical review article that presents a structured physical examination protocol of the rotator cuff for the interested clinician. To fill this void, we present a physical examination protocol developed on the basis of review of prior literature and our clinical experience from dedicated shoulder practices. Our protocol includes range of motion testing by using a goniometer, strength testing by using a dynamometer, and select special tests. Among the many tests for rotator cuff disorders that have been described, we chose ones that have been more thoroughly assessed for sensitivity and specificity. This protocol can be used to isolate the specific rotator cuff tendon involved. The protocol can typically be completed in 15 minutes. We also discuss the clinical implications and limitations of the physical examination maneuvers described in our protocol. This protocol is thorough yet time efficient for a busy clinical practice. It is useful in the diagnosis of rotator cuff tears, impingement syndrome, and biceps pathology.
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Affiliation(s)
- Nitin B Jain
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Boston, MA02115, USA.
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Myer CA, Hegedus EJ, Tarara DT, Myer DM. A user's guide to performance of the best shoulder physical examination tests. Br J Sports Med 2013; 47:903-7. [DOI: 10.1136/bjsports-2012-091870] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Heikenfeld R, Gigis I, Chytas A, Listringhaus R, Godolias G. Arthroscopic reconstruction of isolated subscapularis tears: clinical results and structural integrity after 24 months. Arthroscopy 2012; 28:1805-11. [PMID: 23084151 DOI: 10.1016/j.arthro.2012.06.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 06/04/2012] [Accepted: 06/04/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the magnetic resonance imaging (MRI) and clinical results of arthroscopic repair of isolated subscapularis tears at 24 months' follow-up. METHODS We prospectively followed up 20 patients with isolated subscapularis tears treated with arthroscopic repair with suture anchors in a 3-year period (January 2006 to December 2008) at our institution. Clinical examination of the patients and functional scores (Constant and University of California, Los Angeles [UCLA] scores) were obtained preoperatively and at 6 months, 12 months, and 24 months postoperatively. MRI and routine radiographs were obtained to evaluate the repair at the last follow-up. RESULTS Of the patients (mean age, 42 years; age range, 31 to 56 years), 19 (95%) had complete follow-up. Constant and UCLA scores improved significantly after the repair at all postoperative examinations. The Constant score gained 39.7 points to a mean of 81 points (range, 61 to 95 points) at last follow-up, and the UCLA score improved from 16 points to 32 points (range, 25 to 35 points). Of the shoulders, 13 had a concomitant lesion of the long head of the biceps; 12 were treated with biceps tenodesis. At last follow-up, there were 2 retears detected by both MRI and examinations (positive belly-press and liftoff tests). Seventeen patients were satisfied with their results at 24 months postoperatively. CONCLUSIONS Arthroscopic repair of isolated subscapularis tendon tears is an effective technique with good-to-excellent clinical and functional results. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Roderich Heikenfeld
- Center for Orthopedics and Traumatology, St. Anna Hospital Herne, Herne, Germany.
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Foad A, Wijdicks CA. The accuracy of magnetic resonance imaging and magnetic resonance arthrogram versus arthroscopy in the diagnosis of subscapularis tendon injury. Arthroscopy 2012; 28:636-41. [PMID: 22281195 DOI: 10.1016/j.arthro.2011.10.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 09/30/2011] [Accepted: 10/13/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE The main purpose of this study was to evaluate the accuracy of preoperative magnetic resonance imaging (MRI) in detecting subscapularis tears identified during the gold standard of arthroscopy and determine whether MRI can reliably predict which patients have subscapularis tears. A second purpose was to determine whether magnetic resonance (MR) arthrograms could better identify a subscapularis tear than conventional MRI. METHODS This was a retrospective study evaluating 39 consecutive patients (40 shoulders) who had a preoperative 1.5-T MRI study and underwent an arthroscopic subscapularis tendon repair. All cases were performed between December 2007 and November 2010. RESULTS Subscapularis tears were missed on preoperative MR scanning in 25 of 40 shoulders (62.5%). The sensitivity of noncontrast MRI was 40%, the sensitivity of MR arthrography was 36%, and the overall MR sensitivity was 37.5%. CONCLUSIONS Preoperative 1.5-T MRI of the shoulder does not reliably predict subscapularis tendon tears, regardless of whether conventional MRI or MR arthrography is used. LEVEL OF EVIDENCE Level II, development of diagnostic criteria on basis of consecutive patients with universally applied gold standard.
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Affiliation(s)
- Abdullah Foad
- Quality Care Clinic and Surgery Center, Clinton, Iowa 52732, USA.
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Agneskirchner J, Lafosse L, Kasten P. Arthroskopische Rekonstruktion der Subscapularissehne. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s11678-011-0104-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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