The effects of rotator cuff tear on shoulder proprioception

Shoulder Proprioception: A Review

The purpose of this review is to provide a comprehensive resource for shoulder proprioception assessment and its integration into clinical decision making as well as targeted rehabilitation protocols. Data for this review were acquired from peer-reviewed articles from computerized online databases, namely PubMed and Medline, published between 1906 and 2021. The development of digital/smart phone goniometers can improve shoulder joint range of motion (ROM) measurements and demonstrate comparable measurement accuracy to the universal standard goniometer. The inclinometer offers a portable and cost-effective method for measuring shoulder joint angles and arcs of motion in the vertical plane. Two types of dynamometers, the computerized isokinetic machine and the handheld hydraulic dynamometer, are reliable tools for objective shoulder rotator cuff strength assessment. Motion analysis systems are highly advanced modalities that create three-dimensional models of motion arcs using a series of cameras and reflective beads, offering unparalleled precision in shoulder proprioception measurement; however, they require time-consuming calibration and skilled operators. Advancements in wearable devices and compact mobile technology such as iPhone applications may make three-dimensional motion analysis more affordable and practical for outpatient settings in the future. The complex interplay between proprioception and shoulder dysfunction is not fully understood; however, shoulder proprioception can likely both contribute to and be caused by shoulder pathology. In patients with rotator cuff tears, glenohumeral osteoarthritis, and shoulder instability, clinicians can track proprioception to understand a patient's disease progression or response to treatment. Finally, rehabilitation programs targeting shoulder proprioception have shown promising initial results in restoring function and returning athletes to play.

Relationship between pain and proprioception among individuals with rotator cuff-related shoulder pain

BACKGROUND

Individuals with rotator cuff-related shoulder pain (RCRSP) have altered proprioception. The relationship between shoulder pain and proprioception is not well understood.

PURPOSE

This study aimed to investigate the relationship between shoulder pain and proprioception.

STUDY DESIGN

This was a cross-sectional comparative study.

METHODS

Twenty-two participants with RCRSP (mean age 27.6 ± 4.8 years) and 22 matched pain-free participants (23.4 ± 2.5 years) performed two upper limb active joint position sense tests: (1) the Upper Limb Proprioception Reaching Test (PRO-Reach; reaching toward seven targets) in centimeters and (2) Biodex System at 90% of maximum internal rotation in degrees. Participants performed three memorization and three reproduction trials blindfolded. The proprioception error (PE) is the difference between the memorized and estimation trials. Pain levels were captured pre- and post-evaluation (11-point Likert Numerical Pain Rating Scale). Relationships between PE and pain were investigated using independent t-tests and Spearman rank correlations.

RESULTS

Overall, 22.7% RCRSP participants indicated an increase in pain following the PRO-Reach (X̅ increase of 1.4 ± 1.5 points), while 59% did so with the Biodex (X̅ increase of 2.3 ± 1.8 points), reflecting a clinically important increase in pain. Weak-to-moderate correlations between pain and PEs were found with the Biodex (r = 0.39-0.53) and weak correlations with the PRO-Reach (r = -0.26 to 0.38). Concerning PEs, no significant differences were found between groups with the Biodex (p = 0.32, effect size d = -0.31 [-0.90 to 0.29]). The RCRSP participants demonstrated lower PEs with the PRO-Reach in elevation compared to pain-free participants (global X̅ = 4.6 ± 1.2 cm vs 5.5 ± 1.5 cm; superior 3.8 ± 2.1 cm vs 5.7 ± 2.9 cm; superior-lateral nondominant targets 4.3 ± 2.2 cm vs 6.1 ± 2.8 cm; p = 0.02-0.05, effect size d = 0.72-0.74 [0.12-1.3]).

CONCLUSIONS

Individuals with RCRSP demonstrated better upper limb proprioception in elevation, suggesting a change to interoception (sensory reweighting) in the presence of pain.

Reduced shoulder proprioception due to fatigue after repeated handball throws and evaluation of test-retest reliability of a clinical shoulder joint position test

Background

Proprioception is vital for motor control and can be disturbed, for example, due to fatigue or injury. Clinical feasible, reliable and valid tests of shoulder proprioception are warranted. The aim was to investigate the effects of local fatigue on shoulder proprioception and the reliability of a feasible joint position sense test using an experimental repeated measures design.

Method

Forty participants repeated a shoulder joint position sense test to assess test-retest reliability. The test was then utilized on a subgroup of handball players who were subjected to five bouts of a repeated throwing task with the dominant hand. The effect of local fatigue was investigated by comparing the fatigued with the non-fatigued shoulder.

Results

There was a significant interaction for the arm × bout (p = 0.028, ηp2 = 0.20) and a significant effect for the arm (p = 0.034, ηp2 = 0.35) with a significant decrease in joint position sense for the throwing arm compared to the non-throwing arm. The intraclass correlation coefficient was 0.78 (95% CI = [0.57; 0.89]). The standard error of measurement between trials was 0.70° (range: 0.57°-0.90°).

Discussion

The results indicate that repeated throwing to fatigue disturbs shoulder joint position sense. Assessment with the modified test showed acceptable reliability and can be a valuable assessment tool in the clinic.

Handball players have superior shoulder proprioception: a prospective controlled study

BACKGROUND

Proper proprioceptive and neuromuscular control is crucial for the overhead athlete's performance. The aim of the present study was to evaluate the shoulder joint position sense (JPS) levels in overhead throwing athletes. The secondary aim was to confront the proprioceptive abilities with glenohumeral adaptive changes and pathologies among athletes.

METHODS

Ninety professional handball players and 32 healthy volunteers were recruited. JPS levels were measured by an electronic goniometer and expressed as values of an active reproduction of the joint position (ARJP) and as error of ARJP (EARJP) in 3 different reference positions for each movement (abduction and flexion at 60°, 90°, and 120°; internal [IR] and external rotation [ER] at 30°, 45°, and 60°).

RESULTS

Side-to-side differences revealed significantly better values of EARJP for the throwing shoulders in abduction at 90° and 120°, flexion at 90° and 120°, IR at 60°, and ER at 30° and 60° compared with the nonthrowing shoulders. Handball players showed significantly better proprioceptive levels in their throwing shoulder compared to the dominant shoulder of the control group in abduction at 90° (P = .037) and 120° (P = .001), flexion at 120° (P = .035), IR at 60° (P = .045), and in ER at 60° (P = .012).

DISCUSSION

Handball players present superior shoulder JPS in their dominant throwing shoulder at high range of motion angles when compared to a nonathlete population and to their own nondominant shoulder.

A cross-sectional observational study comparing individuals with a symptomatic full-thickness rotator cuff tear with age-matched controls

Background

A full-thickness rotator cuff tear (FTRCT) is defined as a complete tear of one of the four rotator cuff muscle tendons (supraspinatus, infraspinatus, subscapularis or teres minor). This condition can lead to pain and reduced function. However, not all FTRCT are symptomatic. A better understanding of the characteristics that lead some individuals with FTRCT to experience pain is fundamental to improve strategies used to manage this condition. This level II descriptive study aimed to explore potential sociodemographic, anatomical, psychosocial, pain sensitivity, biomechanical and neuromuscular variables that may differ between individuals with symptomatic FTRCT and age-matched individuals with asymptomatic shoulders.

Methods

In this cross-sectional observational study, adults aged 50 to 80 years of age, either with symptomatic FTRCT or no shoulder pain, were recruited via convenience sampling. Participants filled out questionnaires on sociodemographic and psychosocial variables. Then, various tests were performed, including pain pressure threshold, shoulder range of motion, shoulder muscle strength, shoulder ultrasound and radiologic examination, and sensorimotor functions testing. Each variable was compared between groups using univariate analyses (independent t-tests, Mann-Whitney U tests, exact probability Fisher tests). Significance was set at 0.05.

Results

FTRCT (n = 30) and Control (n = 30) groups were comparable in terms of sex, age, and number of comorbidities. The symptomatic FTRCT group showed a higher proportion of smokers (P = .026) and more participants indicated consuming alcohol or drugs more than they meant to (P = .010). The FTRCT group had a significantly higher prevalence of glenohumeral osteophytes (48% vs. 17%; P = .012). Participants in the FTRCT group were significantly more stressed (P = .04), anxious (P = .003) and depressed (P = .002). The FTRCT group also showed significantly higher levels of pain catastrophisation (P < .001) and sleep disturbance (P < .001). The FTRCT group showed significantly lower range of motion for flexion (P < .001), and external rotation at 0° (P < .001) and 90° (P < .001) of abduction. Isometric strength in both abduction and external rotation were weaker (P = .005) for the FTRCT group.

Conclusion

Sociodemographic, anatomical, psychosocial and biomechanical variables showed statistically significant differences between the FTRCT and Control groups.

Measuring upper limb active joint position sense: Introducing a new clinical tool - The Upper Limb Proprioception Reaching Test

BACKGROUND

Proprioception is our sense of body awareness, including the sub-category of active joint position sense (AJPS). AJPS is fundamental to joint stability and movement coordination. Despite its importance, there remain few confident ways to measure upper limb AJPS in a clinic.

OBJECTIVE

To assess a new AJPS clinical tool, the Upper Limb Proprioception Reaching Test (PRO-Reach; seven targets), for discriminant validity, intra-rater and absolute reliability.

DESIGN

Cross-sectional measurement study.

METHODS

Seventy-five healthy participants took part in a single session with 2 consecutive evaluations (E1 and E2) (within-day reliability). Twenty participants were randomly selected to perform a dominant shoulder fatigue protocol (discriminant validity), whereafter a third evaluation was repeated (E3). The PRO-Reach was analyzed with paired t tests (discriminant validity), intra-class correlation coefficients (ICCs) and minimal detectable change [MDC]) (intra-rater: within-day and between-trial relative and absolute reliability).

RESULTS

The PRO-Reach supports moderate (mostly superior targets) to excellent (mostly inferior targets) reliability. Between-trial ICCs (T1/T2/T3) varied between 0.72 and 0.90, and within-day (E1/E2) ICCs between 0.45 and 0.72, with associated MDC95 values (3.9-5.0 cm). The overall scores (seven targets) supported the strongest within-day reliability (ICC = 0.77). The inferior targets demonstrated the highest between-trial and within-day reliability (ICCs = 0.90 and 0.72). A fatigue effect was found with the superior and superior-lateral targets (P < .05).

CONCLUSIONS

The inferior targets and overall scores demonstrate the strongest reliability. The use of the PRO-Reach tool may be suitable for clinical use upon further psychometric testing amongst pathological populations.

LEVEL OF EVIDENCE

Level III cross-sectional study.

Ageing and joint position sense of the asymptomatic shoulder: An observational study

PURPOSE

This study aimed to quantify the extent to which age was associated with joint position sense (JPS) of the asymptomatic shoulder as measured by joint position reproduction (JPR) tasks and assess the reproducibility of these tasks.

METHODS

120 Asymptomatic participants aged 18-70 years each performed 10 JPR-tasks. Both contralateral and ipsilateral JPR-tasks were evaluated on accuracy of JPR under active- and passive conditions at two levels within the shoulder forward flexion trajectory. Each task was performed three times. In a subgroup of 40 participants, the reproducibility of JPR-tasks was assessed one week after initial measurement. Reproducibility of JPR-tasks was evaluated by both reliability (intra-class correlation coefficients (ICC's)) and agreement (standard error of measurement (SEM)) measures.

RESULTS

Age was not associated with increased JPR-errors for any of the contralateral or ipsilateral JPR-tasks. ICC's ranged between 0.63 and 0.80 for contralateral JPR-tasks, and from 0.32 to 0.48 for ipsilateral tasks, except for one ipsilateral task where the reliability was similar to contralateral tasks (0.79). The SEM was comparable and small for all JPR-tasks, ranging between 1.1 and 2.1.

CONCLUSION

No age-related decline in JPS of the asymptomatic shoulder was found, and good agreement between test and re-test measurements for all JPR-tasks as indicated by the small SEM.

Is shoulder joint position sense affected in partial and full-thickness supraspinatus tears?

PURPOSE

Neuromuscular control is important for joint stabilization. Supraspinatus muscle plays an essential role in the perception of proprioceptive sense. The aim of this study is to investigate active joint position sense (AJPS) both in patients with partial and full-thickness supraspinatus tears and in healthy participants.

METHODS

Twenty patients with partial supraspinatus tears, 20 patients with full-thickness supraspinatus tears, and 20 healthy participants, aged 40-65 years, were included in the study. Proprioceptive sense was assessed with AJPS measurement. Absolute error was calculated to evaluate joint position sense.

RESULTS

Active joint position sense was decreased in partial and full-thickness tears on both in affected and contralateral shoulders compared to control group (p < 0.05). There was no difference between groups with partial and full-thickness tears on the affected and contralateral shoulders at 40° and 100° elevation (p > 0.05).

CONCLUSION

AJPS was affected after supraspinatus injury. It was seen as proprioceptive deficit in patients with partial and full-thickness tears in both affected and contralateral shoulders.

Assessment of shoulder proprioception in patients with chronic mechanical cervical pain: A comparative study

BACKGROUND

Chronic mechanical cervical pain (CMCP) is a common disabling problem worldwide, interfering with upper extremities function. However studying the impact of CMCP on shoulder proprioception is still lacking.

OBJECTIVE

To investigate the impact of CMCP on shoulder proprioception in young adults compared with normal control (NC) individuals.

METHODS

A comparative study was conducted between two groups; 40 patients with CMCP (mean age 32.28 ± 6.586) and 40 age and sex matched NC (mean age 33.43 ± 9.021). The Biodex isokinetic dynamometer was used to assess shoulder active sense of position at 30∘ external and internal rotations. The absolute angular error was calculated for the dominant and non-dominant shoulders.

RESULTS

The absolute angular error was significantly increased only in the CMCP at both rotation angles for both shoulders, showing a remarkable increase on the dominant shoulder and in the external rotation range compared with NC.

CONCLUSIONS

CMCP can significantly impair shoulder proprioception, particularly on the dominant side and in external rotation range. This could emphasize the careful examination of shoulder proprioception for the early detection of shoulders at risk, to eliminate the possibility of shoulder instability and/or injury in young adults with CMCP.

THE INTER-RATER AND INTRA-RATER RELIABILITY OF GLENOHUMERAL JOINT POSITION AND MOVEMENT SENSE TESTS APPLIED USING AN ISOKINETIC DYNAMOMETER

Purpose: The aim of this study was to test the inter-rater and intra-rater reliability of glenohumeral joint (GHJ) position and movement sense tests of an isokinetic dynamometer in healthy individuals. Methods: The study included 17 healthy subjects. GHJ position and movement sense tests were applied with an isokinetic dynamometer to the dominant extremity. Results: The different error types calculated for position sense were in the range of mean 0.02±1.62 - 5.42±1.74. The ICC value for the different error types was determined in the range of 0.038 - 0.657 for the intra-rater tests, and 0.095 - 0.779 for the inter-rater tests. The movement sense test results for different directions and angles ranged from 9.61±2.61 to 11.18±2.89. The ICC values for movemeent sense were in the range of 0.687 – 0.912 for the intra-rater tests, and 0.844 - 0.925 for the inter-rater tests. Conclusion: The isokinetic dynamometer showed moderate-good intra-rater and inter-rater test reliability in the measurement of the GHJ internal rotation movement sense. The intra-rater test reliability was poor in external rotation but the inter-rater test reliability was moderate-good. However in the measurement of movement sense, the isokinetic dynamometer showed intra-rater and inter-rater test reliability at an excellent level. The conformity of both the position and the movement sense tests, and therefore, the repeatability, was extremely good.

Subacromial Impingement Syndrome: A Systematic Review of Existing Treatment Modalities to Newer Proprioceptive-Based Strategies

Musculoskeletal pain is a common reason for primary care visits, with many visits for shoulder pain due to subacromial impingement syndrome (SIS). Current treatments lack evidence for effective management, showing only temporary outcomes. This systematic review evaluates existing modalities in comparison to the use of more permanent proprioceptive-based strategies. Specifically, this meta-analysis compared the use of kinesiology tape, myofascial trigger point release (MPTR), scapular stabilization exercises (SSE), and resistance training. PubMed, BioMedCentral, and ScienceDirect databases were queried for studies evaluating proprioceptive-based exercises in the last nine years. In total, 48 studies met the inclusion and exclusion criteria. After removing duplicates, a total of 14 level 1 studies were left. Kinesiology tape use demonstrated a statistically significant reduction in pain-free range of motion. MPTR improved in all pain scores and the disability scores index. SSE also reduced pain; however, mixed results were seen for range of motion. Finally, resistance training not only reduced pain but improved proprioception and joint position sense. Even though all techniques showed some promise in treating SIS, further large-scale studies exploring related outcomes are needed.

Role of active joint position sense on the upper extremity functional performance tests in college volleyball players

Background

It has been well established that proprioception plays a decisive role in shoulder stability and sport performance. Notwithstanding, there is a lack of clear association between active joint position sense (AJPS) and the performance of upper-extremity functional performance tests. The aim of this study was to determine whether the AJPS of the shoulder complex is associated with the performance of college volleyball players with the following functional tests: Y-Balance Test-Upper Quarter (YBT-UQ), Closed Kinetic Chain Upper-Extremity Stability Test (CKCUEST), and Seated Medicine Ball Throw (SMBT). The secondary aim was to investigate whether the magnitude of the proprioception error through the AJPS had the ability to act as a predictor for functional test scores.

Methods

Cross-sectional study with a convenience sampling. Healthy college volleyball players (≥12 h of training/week), 30 males and 22 females, between 18 and 26 years of age were included. AJPS of the shoulder (90° of flexion (90°Flex), 90° of internal rotation at 90° of abduction (90°IR/ABD), 90° of external rotation at 90° of abduction (90°ER/ABD)) and three upper-extremity functional performance tests (YBT-UQ, CKCUEST and SMBT) were assessed. A Pearson's test and a stepwise multiple linear regression analysis were used to determine possible associations and relationships between outcome measures, respectively.

Results

The analysis revealed that AJPS at 90°IR/ABD and 90°ER/ABD were the only proprioceptive variables with an association to the YBT-UQ and SMBT. Despite these relationships, only the AJPS at 90°IR/ABD was associated with the performance of the YBT-UQ in; superolateral direction (β = -0.7; 95% CI [-1.3 to 0.1]; p = 0.025); inferolateral direction (β = -1.5; 95% CI [-2.1 to -0.8]; p = 0.001); and composite score (β = -0.8; 95% CI [-1.3 to -0.3]; p = 0.002). From these, AJPS at 90°IR/ABD mainly explained the variability of YBT-UQ (inferolateral direction) performance (R² = 0.32; %R² = 0.32). Our findings allow for a possible expanded role for proprioception as a contributing factor in upper limb motor control during functional movements. Further research is required to explore and distinguish the associations between proprioception, motor control and sport performance involving the upper limbs.

Delayed detection of passive motion in shoulders with a rotator cuff tear

The aim of this study was to test whether or not the threshold to the detection of passive motion (TTDPM) and passive joint position sense on the affected shoulder of patients with rotator cuff tear (RCT) was impaired compared to those on the unaffected side and to investigate the relationship between the tear size and changes in the TTDPM and passive joint position sense induced by RCT. This study included 21 patients with unilateral RCT before arthroscopic rotator cuff repair. To investigate proprioception in this study, we measured the TTDPM and passive joint position sense in abduction and external rotation using an isokinetic dynamometer. The tear size was evaluated intraoperatively under direct arthroscopic visualization. The TTDPM in abduction and external rotation was significantly longer on the affected side than on the unaffected side. However, the angular absolute error in passive joint position sense in abduction and external rotation was not significantly different between the limbs. A comparison according to the tear size impaired proprioception of the TTDPM in the larger tear group showed significantly longer values than in the smaller group. There was impaired proprioception of TTDPM in patients with RCT, and the impaired proprioception was related to tear severity. Impaired proprioception of TTDPM may inhibit consistent muscle recruitment to achieve precise control. Our results suggest that clinicians should consider proprioceptive exercises for impaired proprioception in their treatment for conservative or postoperative patients.

Criteria for Return-to-Play (RTP) after Rotator Cuff Surgery: A Systematic Review of Literature

This systematic review of the literature aimed to highlight which criteria are described in the literature to define when a patient, after rotator cuff repair (RCR), is ready for return-to-play (RTP), which includes return to unrestricted activities, return to work, leisure, and sport activities. An online systematic search on the US National Library of Medicine (PubMed/MEDLINE), SCOPUS, Web of Science (WOS), and the Cochrane Database of Systematic Reviews, was performed with no data limit until December 2021. A total of 24 studies that reported at least one criterion after RCR were included. Nine criteria were identified and among these, the most reported criterion was the time from surgery, which was used by 78% of the studies; time from surgery was used as the only criterion by 54% of the studies, and in combination with other criteria, in 24% of the studies. Strength and ROM were the most reported criteria after time (25%). These results are in line with a previous systematic review that aimed to identify RTP criteria after surgical shoulder stabilization and with a recent scoping review that investigated RTP criteria among athletes after RCR and anterior shoulder stabilization. Compared to this latest scoping review, our study adds the methodological strength of being conducted according to the Prisma guidelines; furthermore, our study included both athletes and non-athletes to provide a comprehensive view of the criteria used after RCR; moreover, ten additional recent manuscripts were examined with respect to the scoping review.

A technique for repairing rotator cuff transtendinous tears with a remnant attached to the footprint

BACKGROUND

Some unusual rotator cuff (RC) tears are located in more proximal tendinous portions, with substantial remnant tissue attached to the footprint. The two options for surgical repair are sacrificing or preserving the remnant tissue. We introduce a surgical repair technique that preserves as much of the remnant footprint as possible.

SURGICAL TECHNIQUE

A double-loaded suture anchor is inserted into the subchondral bone at the medial portion of the RC footprint; the lateral remnant tissue is preserved. Each strand is shuttled and repassed through the medial portion of the tendon in a mattress fashion using a suture hook device. Then, multiple no. 1 PDS sutures are passed through the medial and lateral stumps and left untied. Strands from the suture anchor are first tied in a double mattress fashion. Then, the repair is completed by tying the remaining no. 1 PDS sutures.

CONCLUSIONS

We propose a remnant-preserving RC repair technique for transtendinous RC tears with sufficient tissue remaining within the RC footprint. This technique appears advantageous in terms of re-establishing an environment that promotes tendon healing after repair.

3D motion analysis of latissimus dorsi tendon transfer in patients with posterosuperior rotator cuff tears: Analysis of proprioception and the ability to perform ADLS

BACKGROUND

Massive irreparable posterosuperior rotator cuff tears may result in a loss of external rotation. Most of these patients lose their ability to perform activities of daily living (ADLs), especially where external rotation and abduction are needed. Latissimus dorsi tendon transfer (LDTT) is a method to restore abduction and external rotation in patients with posterosuperior rotator cuff tears. There are no objective data concerning whether LDTT can restore range of motion (ROM), especially in performing ADLs and if proprioception changes after LDTT.

METHODS

We examined 12 patients 4.2 years (1-9 years) after LDTT with simultaneous 3D motion analysis; the opposite, nonaffected side was assessed as control. The measurement protocol included maximum values in flexion/extension, abduction/adduction, internal/external rotation in 0° and in 90° flexion and in 90° abduction. To evaluate competences, we measured seven activities of daily life and examined the proprioceptive ability using an active angle reproduction test.

RESULTS

In total, 4.2 years (1-9 years) after LDTT there was no significant difference in flexion/extension and abduction/adduction compared to the healthy side. Maximum external rotation was significantly reduced compared to the opposite side. Eleven patients (85%) were able to perform all ADL. Proprioceptive ability did not differ from the healthy side.

CONCLUSION

LDTT cannot fully restore a patient's ability for external rotation after a posterosuperior rotator cuff tear. However, 4.2 years after surgery, 85% of the patients are able to perform all ADLs. Proprioceptive ability is not affected by the transfer.