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Small KM, Adler RS, Shah SH, Roberts CC, Bencardino JT, Appel M, Gyftopoulos S, Metter DF, Mintz DN, Morrison WB, Subhas N, Thiele R, Towers JD, Tynus KM, Weissman BN, Yu JS, Kransdorf MJ. ACR Appropriateness Criteria ® Shoulder Pain-Atraumatic. J Am Coll Radiol 2019; 15:S388-S402. [PMID: 30392607 DOI: 10.1016/j.jacr.2018.09.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/07/2018] [Indexed: 01/25/2023]
Abstract
Shoulder pain is one of the most common reasons for musculoskeletal-related physician visits. Imaging plays an important role in identifying the specific cause of atraumatic shoulder pain. This review is divided into two parts. The first part provides a general discussion of various imaging modalities (radiographs, arthrography, nuclear medicine, ultrasound, CT, and MRI) and their usefulness in evaluating atraumatic shoulder pain. The second part focuses on the most appropriate imaging algorithms for specific shoulder conditions including: rotator cuff disorders, labral tear/instability, bursitis, adhesive capsulitis, biceps tendon abnormalities, postoperative rotator cuff tears, and neurogenic pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | | | - Shaan H Shah
- Research Author, Brigham & Women's Hospital, Boston, Massachusetts
| | | | - Jenny T Bencardino
- Panel Vice-Chair, New York University School of Medicine, New York, New York
| | - Marc Appel
- James J. Peters VA Medical Center, Bronx, New York; American Academy of Orthopaedic Surgeons
| | | | - Darlene F Metter
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | | | | | - Ralf Thiele
- University of Rochester School of Medicine and Dentistry, Rochester, New York; American College of Rheumatology
| | - Jeffrey D Towers
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katherine M Tynus
- Northwestern Memorial Hospital, Chicago, Illinois; American College of Physicians
| | | | - Joseph S Yu
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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Avila Lafuente JL, Moros Marco S, García Pequerul JM. Controversies in the Management of the First Time Shoulder Dislocation. Open Orthop J 2018; 11:1001-1010. [PMID: 29430264 PMCID: PMC5789581 DOI: 10.2174/1874325001711011001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 10/21/2016] [Accepted: 10/28/2016] [Indexed: 01/18/2023] Open
Abstract
Background: Traditionally, initial management of first anterior shoulder dislocations consists of reduction of the glenohumeral joint followed by a period of immobilization and subsequent physical therapy to recover shoulder range of motion and strength. This traditional approach in management is now controversial due to the high rate of recurrence. The aim of this paper is to review and discuss the literature about the global management of patients presenting with first-time traumatic anterior glenohumeral dislocation, analyzing the factors that affect shoulder instability after the first episode of dislocation. Methods: Scientific publications about the management of first-time shoulder dislocations are reviewed. Pubmed is used for that and no limit in the year of publication are stablished. These papers and their conclusions are discussed. Results: Younger patients, patient´s activities and the kind of injury are the most important factors related to the shoulder instability after a first time traumatic dislocation. Authors that recommend surgical treatment after the first episode of dislocation argue that the possibilities of recurrence are high and therefore surgery should be performed before its occurrence. Other authors, however, argue that surgical treatment is demanding, and keep in mind that complications, such as recurrence, stiffness and pain after surgery, are still present. Conclusion: Currently, there is still no consensus in the literature with regard to the management of first episode of shoulder dislocation. It is necessary to analyze carefully every individual case to manage them more or less aggressive to obtain the best result in our practice.
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Glenohumeral Joint Kinematics following Clavicular Fracture and Repairs. PLoS One 2017; 12:e0164549. [PMID: 28060814 PMCID: PMC5218560 DOI: 10.1371/journal.pone.0164549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 09/07/2016] [Indexed: 11/20/2022] Open
Abstract
Background The purpose of this biomechanical study was to determine the effect of shortened clavicle malunion on the center of rotation of the glenohumeral (GH) joint, and the capacity of repair to restore baseline kinematics. Methods Six shoulders underwent automated abduction (ABD) and abbreviated throwing motion (ATM) using a 7-DoF automated upper extremity testing system in combination with an infrared motion capture system to measure the center of rotation of the GH joint. ATM was defined as pure lateral abduction and late cocking phase to the end of acceleration. Torsos with intact clavicle underwent testing to establish baseline kinematics. Then, the clavicles were subjected to midshaft fracture followed by kinematics testing. The fractured clavicles underwent repairs first by clavicle length restoration with plate fixation, and then by wiring of fragments with a 2-cm overlap to simulate shortened malunion. Kinematic testing was conducted after each repair technique. Center of rotation of the GH joint was plotted across all axes to outline 3D motion trajectory and area under the curve. Results Throughout ABD, malunion resulted in increased posterior and superior translation compared to baseline. Plate fixation restored posterior and superior translations at lower abduction angles but resulted in excess anterior and inferior translation at overhead angles. Throughout ATM, all conditions were significantly anterior and superior to baseline. Translation with malunion was situated anterior to the fractured and ORIF conditions at lower angles of external rotation. Plate fixation did not restore baseline anteroposterior or superoinferior translation at any angle measured. Conclusions This study illustrates the complex interplay of the clavicle and the GH joint. While abnormal clavicle alignment alters shoulder motion, restoration of clavicle length does not necessarily restore GH kinematics to baseline. Rehabilitation of the injured shoulder must address the osseous injury and the dynamic forces of the shoulder girdle.
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Abstract
Imaging of the shoulder forms an important adjunct in clinical decision making in patients with shoulder instability. The typical lesions related with classic anterior and anteroinferior shoulder dislocation are an anteroinferior labral avulsion with or without bony fragment of bone loss – a (bony) Bankart lesion – and a posterolateral humeral head impaction fracture – the Hill-Sachs lesions. These are relatively straightforward to identify on imaging, although normal variants of the inferior labrum and variants of labral damage may cause confusion. Other capsuloligamentous lesions, often associated with less typical types of instability, are much more difficult to identify correctly on imaging, as they occur in the anterosuperior part of the glenohumeral joint with its many normal variants or because they result in more subtle, and therefore easily overlooked, changes in morphology or signal intensity. This paper aims at describing the appearance of the normal and pathologic glenohumeral joint related to shoulder instability. Ample reference will be given as to why identification of abnormalities, whether normal or pathologic, is important to the surgeon facing a treatment decision.
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Szyluk KJ, Jasiński A, Mielnik M, Koczy B. Incidence of Posttraumatic Shoulder Dislocation in Poland. Med Sci Monit 2016; 22:3967-3974. [PMID: 27777396 PMCID: PMC5091219 DOI: 10.12659/msm.900902] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The incidence of shoulder joint dislocation has been estimated at 11–26 per 100 000 population per year. In our opinion, basic epidemiological data need to be continually updated in studies of large populations. To study the incidence of posttraumatic dislocation of the shoulder joint in the Polish population. Material/Methods We retrospectively investigated the entire Polish population between 1 January 2010 and 1 January 2015. To identify the study group, data collected in the electronic database of the National Health Fund were used. The study group was divided into subgroups to detect possible differences in the incidence of shoulder dislocation with regard to age, sex, and season of the year (month) when the dislocation occurred. Results The cumulative size of the study sample was 192.72 million over the 5 years of the study. We identified 51 409 patients with first posttraumatic shoulder dislocation, at a mean age of 50.83 years (SD 21.12), from 0 to 104 years. The incidence of traumatic shoulder dislocations for the entire study group ranged from 24.75/100 000/year (number of posttraumatic shoulder dislocations per 100 000 persons per year) to 29.09/100 000/year, for a mean of 26.69/100 000/year. Conclusions In this study, the overall incidence of first-time posttraumatic shoulder dislocations in the Polish general population was 26.69 per 100 000 persons per year. These results are higher than estimates presented by other authors. It is necessary to study, regularly update, and monitor this problem in the general population.
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Affiliation(s)
- Karol J Szyluk
- Department of Hand Surgery, District Hospital of Orthopedics and Trauma Surgery, Piekary Śląskie, Poland
| | - Andrzej Jasiński
- Department of Hand Surgery, District Hospital of Orthopedics and Trauma Surgery, Piekary Śląskie, Poland
| | - Michał Mielnik
- Department of the Knee Surgery, Arthroscopy and Sports Traumatology, District Hospital of Orthopedics and Trauma Surgery, Piekary Śląskie, Poland
| | - Bogdan Koczy
- Department of Trauma and Orthopaedics, District Hospital of Orthopedics and Trauma Surgery, Piekary Śląskie, Poland
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Roy EA, Cheyne I, Andrews GT, Forster BB. Beyond the Cuff: MR Imaging of Labroligamentous Injuries in the Athletic Shoulder. Radiology 2016; 278:316-32. [PMID: 26789600 DOI: 10.1148/radiol.2015150364] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Shoulder disease is common in the athletic population and may arise as a consequence of a single traumatic episode or multiple repeated events. Associated labroligamentous injuries can result in substantial disability. Specific athletic and occupational activities result in predictable injury patterns. Imaging in general and magnetic resonance (MR) imaging, in particular, are vital in establishing the correct diagnosis and excluding common mimicking conditions, to ensure timely and appropriate management. In this review, the utility of MR imaging and MR arthrography will be explored in evaluation of shoulder disease, taking into account normal variants of the labroligamentous complex. Subsequently, broad categories of labral lesions and instability, external and internal impingement, as well as nerve entrapment syndromes, will be discussed, while emphasizing their imaging findings in the clinical context and illustrating key features. More recent concepts of internal impingement and secondary subacromial impingement will also be clarified.
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Affiliation(s)
- Elizabeth A Roy
- From the Department of Radiology, University of British Columbia Hospital, 2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5
| | - Ian Cheyne
- From the Department of Radiology, University of British Columbia Hospital, 2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5
| | - Gordon T Andrews
- From the Department of Radiology, University of British Columbia Hospital, 2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5
| | - Bruce B Forster
- From the Department of Radiology, University of British Columbia Hospital, 2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5
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Szyluk K, Jasiński A, Widuchowski W, Mielnik M, Koczy B. Results of Arthroscopic Bankart Lesion Repair in Patients with Post-Traumatic Anterior Instability of the Shoulder and a Non-Engaging Hill-Sachs Lesion with a Suture Anchor after a Minimum of 6-Year Follow-Up. Med Sci Monit 2015; 21:2331-8. [PMID: 26256225 PMCID: PMC4536886 DOI: 10.12659/msm.894387] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Shoulder instability is an important clinical problem. Arthroscopic surgery is an established treatment modality in shoulder instability, but it continues to be associated with a high rate of recurrences and complications. The purpose of the study was to analyze late outcomes of arthroscopic repair of Bankart lesions in patients with post-traumatic anterior shoulder instability and non-engaging Hill-Sachs lesion, with special focus on the incidence and causes of recurrences and complications. Material/Methods We investigated 92 patients (92 shoulders) who underwent surgery on account of post-traumatic anterior shoulder instability. The duration of follow-up ranged from 6 to 12.5 years (mean: 8.2 years). All patients were operated on in the lateral decubitus position using FASTak 2.8-mm suture anchors (FASTak, Arthrex, Naples, Florida). Treatment outcomes were evaluated using the Rowe and University of California at Los Angeles rating system (UCLA). Results According to Rowe scores, there were 71 (81.5%) excellent, 12 (12.6%) good, 5 (5.3%) satisfactory, and 2 (2.1%) poor results. Rowe scores improved in a statistically significant manner (p=0.00) post-surgery, to a mean of 90 (range: 25–100). Treatment outcomes measured as UCLA scores improved in a statistically significant manner (p=0.00), reaching post-operative levels of 12–35 (mean: 33.5). There were 9 recurrences, 1 case of axillary nerve praxia, and 1 case of anchor loosening. Conclusions With rigorous criteria for qualifying patients for surgery, arthroscopic treatment of post-traumatic anterior shoulder instability produces good outcomes and low recurrence and complication rates irrespective of the number of previous dislocations, age, or sex.
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Affiliation(s)
- Karol Szyluk
- Department of Hand Surgery, District Hospital of Orthopedics and Trauma Surgery, Piekary Śląskie, Poland
| | - Andrzej Jasiński
- Department of Hand Surgery, District Hospital of Orthopedics and Trauma Surgery, Piekary Śląskie, Poland
| | - Wojciech Widuchowski
- Department of the Knee Surgery, Arthroscopy and Sports Traumatology, District Hospital of Orthopedics and Trauma Surgery, Piekary Śląskie, Poland
| | - Michał Mielnik
- Department of the Knee Surgery, Arthroscopy and Sports Traumatology, District Hospital of Orthopedics and Trauma Surgery, Piekary Śląskie, Poland
| | - Bogdan Koczy
- Department of Trauma and Orthopaedics, District Hospital of Orthopedics and Trauma Surgery, Piekary Śląskie, Poland
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Sharma P, Morrison WB, Cohen S. Imaging of the Shoulder with Arthroscopic Correlation. Clin Sports Med 2013; 32:339-59. [DOI: 10.1016/j.csm.2013.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
The overhead throwing motion is a complex sequence of maneuvers that requires coordinated muscle activity in the upper and lower extremities. The shoulder and elbow are subject to multidirectional forces and are particularly vulnerable to injury during specific phases of the overhead throwing motion. Ligamentous, tendinous, neural, and osseous pathology that may occur in the shoulder or elbow of an overhead-throwing athlete will be discussed, with an emphasis on the role of MR imaging and MR arthrography.
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Affiliation(s)
- Neel B Patel
- Department of Radiology, University of Chicago Medical Center, 5841 South Maryland Avenue, MC2026, Chicago, IL 60637, USA.
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Cohn RM, Jazrawi LM. The Throwing Shoulder: the Orthopedist Perspective. Magn Reson Imaging Clin N Am 2012; 20:261-75, x. [DOI: 10.1016/j.mric.2012.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Macmahon PJ, Palmer WE. Magnetic resonance imaging in glenohumeral instability. Magn Reson Imaging Clin N Am 2012; 20:295-312, xi. [PMID: 22469405 DOI: 10.1016/j.mric.2012.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The glenohumeral joint enables tremendous range of motion at the expense of stability. Functional stability is maintained by the synchronous coordination of complex static and dynamic structures. Symptomatic glenohumeral instability most often results from injury to the inferior labral-ligamentous complex, the primary passive stabilizer of the shoulder. This article reviews the structures important in glenohumeral stabilization and illustrates their normal appearances and the abnormalities associated with anterior, posterior, and multidirectional instability. These lesions are discussed in the context of therapeutic decision making.
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Affiliation(s)
- Peter J Macmahon
- Department of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, YAW 6030, Boston, MA 02114, USA.
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Taljanovic MS, Nisbet JK, Hunter TB, Cohen RP, Rogers LF. Humeral avulsion of the inferior glenohumeral ligament in college female volleyball players caused by repetitive microtrauma. Am J Sports Med 2011; 39:1067-76. [PMID: 21257845 DOI: 10.1177/0363546510391155] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Humeral avulsion of the inferior glenohumeral ligament is a rare injury resulting from hyperabduction and external rotation, and it is most commonly seen with sports-related injuries, including those from volleyball. The anterior band of the inferior glenohumeral ligament is most commonly injured (93%), whereas the posterior band is infrequently injured. The axillary pouch humeral avulsion of the inferior glenohumeral ligament as a result of repetitive microtrauma has not been yet described in the English literature. HYPOTHESIS Humeral avulsions of the inferior glenohumeral ligaments are identifiable in volleyball players without acute injuries, and they have a unique pathologic pattern in these athletes. STUDY DESIGN Case series; Level of evidence, 4. METHODS Four female college volleyball players with pain in their dominant shoulder and with inferior capsular laxity and/or instability—without a known history of trauma or dislocation of the same shoulder—were referred by an experienced sports medicine orthopaedic surgeon for the magnetic resonance arthrogram procedure of the same shoulder. The imaging findings were retrospectively correlated with the initial interpretation and arthroscopic findings. RESULTS All 4 patients had an axillary pouch humeral avulsion of the inferior glenohumeral ligament. Three had articular surface partial-thickness rotator cuff tear, and 3 had a labral tear. All were outside hitters or middle blockers who consequently performed multiple hitting maneuvers in practice and games. CONCLUSION Repetitive microtrauma from overhead hitting in volleyball generates forces on the inferior capsule of the shoulder joint that may cause inferior capsular laxity and subsequent failure of the humeral side of the axillary pouch portion of the inferior glenohumeral ligament.
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Affiliation(s)
- Mihra S Taljanovic
- Department of Radiology, The University of Arizona HSC, Tucson, Arizona 85724, USA.
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Arliani GG, Astur DDC, Cohen C, Ejnisman B, Andreoli CV, Pochini AC, Cohen M. Surgical versus nonsurgical treatment in first traumatic anterior dislocation of the shoulder in athletes. Open Access J Sports Med 2011; 2:19-24. [PMID: 24198566 PMCID: PMC3781878 DOI: 10.2147/oajsm.s17378] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Anterior traumatic dislocation is a common problem faced by orthopedic surgeons. After the first episode of shoulder dislocation, a combination of lesions can lead to chronic instability. The management in treatment of young athletes after the first acute anterior shoulder dislocation is controversial. The available literature supports early surgical treatment for young male athletes engaged in highly demanding physical activities after the first episode of traumatic dislocation of the shoulder. This is because of the best functional results and lower recurrence rates obtained with this treatment in this population. However, further clinical trials of good quality comparing surgical versus nonsurgical treatment for well-defined lesions are needed, especially for categories of patients who have a lower risk of recurrence.
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Affiliation(s)
- Gustavo Gonçalves Arliani
- Centro de Traumatologia do Esporte (CETE), Departamento de Ortopedia e Traumatologia da Universidade Federal de São Paulo, São Paulo, Brazil
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