Sports and performing arts medicine. 2. Shoulder and elbow overuse injuries in sports

Development of a mouse model of supraspinatus tendon insertion site healing

Supraspinatus (SS) tendon tears are common musculoskeletal injuries whose surgical repair exhibits the highest incidence of re-tear of any tendon. Development of therapeutics for improving SS tendon healing is impaired by the lack of a model that allows biological perturbations to identify mechanisms that underlie ineffective healing. The objective of this study was to develop a mouse model of supraspinatus insertion site healing by creating a reproducible SS tendon detachment and surgical repair which can be applied to a wide array of inbred mouse strains and genetic mutants. Anatomical and structural analyses confirmed that the rotator cuff of the mouse is similar to that of human, including the presence of a coracoacromial (CA) arch and an insertion site that exhibits a fibrocartilagenous transition zone. The surgical repair was successfully conducted on seven strains of mice that are commonly used in Orthopaedic Research suggesting that the procedure can be applied to most inbred strains and genetic mutants. The quality of the repair was confirmed with histology through 14 days after surgery in two mouse strains that represent the variation in mouse strains evaluated. The developed mouse model will allow us to investigate mechanisms involved in insertion site healing.

Lateral scapular slide test and scapular mobility in volleyball players

CONTEXT

The stability of the scapula in relation to the entire moving upper extremity is the key in the throwing sequence. The importance of scapular positioning in volleyball players has been well documented in the literature, but no one has compared scapular positioning between volleyball players and sedentary people.

OBJECTIVE

To compare measurements of scapular mobility obtained using the lateral scapular slide test between volleyball players and sedentary participants without shoulder impairments and to compare changes in scapular mobility in players according to the number of years of sport participation.

DESIGN

Randomized controlled clinical trial.

SETTING

University research laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 121 people at a single university volunteered. Of these, 67 were sedentary (age = 24.3 ± 2.34 years, height = 1.69 ± 0.09 m, mass = 65.1 ± 11.91 kg); 54 were volleyball players from 4 professional teams and were separated into 2 groups according to their years of sport participation. The first group was named young players (n = 31; age = 17.7 ± 2.58 years, height = 1.83 ± 0.10 m, mass = 68.3 ± 12.21 kg, sport participation ≤ 9 years), and the second group was named old players (n = 23; age = 26.9 ± 3.39 years, height = 1.95 ± 4.38 m, mass = 90.7 ± 5.75 kg, sport participation ≥ 10 years).

MAIN OUTCOME MEASURE(S)

Study participants completed a rating scale for pain and a questionnaire about demographic and shoulder problems. One assessor performed the lateral scapular slide test and additional flexibility measurements around the shoulder girdle. Flexibility (external rotation, internal rotation) and scapular position (1, 2, 3) were compared among groups (young players, old players, sedentary people) and between sides (dominant, nondominant).

RESULTS

In sedentary participants, we found differences for position 1 (t(66) = 3.327, P = .002), position 2 (t(66) = 2.491, P = .004), position 3 (t(66) = 2.512, P = .006), and internal rotation (t(66) = 2.592, P = .001) between the dominant and nondominant sides. In old players, we found differences for position 2 between the dominant and nondominant sides (t(22) = 2.956, P = .004). For position 2 (F(2,118) = 4.265, P = .02) and position 3 (F(2,118) = 4.702, P = .01), we found differences between young and old players. For internal rotation, we found differences between sedentary and old players (F(2,118) = 6.578, P = .002) and between young and old players (F(2,118) = 3.723, P = .01).

CONCLUSIONS

Clinicians evaluating overhead athletes need to remember that asymmetric scapular posture between the dominant and nondominant sides in unilateral overhead athletes might be normal and not necessarily related to injury.

Proximal wrist extensor tendinopathy

Proximal wrist extensor tendinopathy, which is also known as tennis elbow, is pain at or just distal to the lateral humeral epicondyle within the proximal wrist extensor tendon. It occurs commonly in certain athletes but can also occur in people with jobs that require repetitive movements of the hand and upper limb. In most cases the tendon involved shows no signs of inflammation or tendonitis, but instead shows fibroblasts, vascular hyperplasia, and disorganized collagen. Diagnosis is often made by history and physical exam alone. Most people respond to conservative measures including activity modification, analgesics, manipulation of tissue, and exercise. In some cases, an injection of corticosteroid or botulinum toxin may be used. Surgery is rarely needed.

Scapular winging: anatomical review, diagnosis, and treatments

Scapular winging is a rare debilitating condition that leads to limited functional activity of the upper extremity. It is the result of numerous causes, including traumatic, iatrogenic, and idiopathic processes that most often result in nerve injury and paralysis of either the serratus anterior, trapezius, or rhomboid muscles. Diagnosis is easily made upon visible inspection of the scapula, with serratus anterior paralysis resulting in medial winging of the scapula. This is in contrast to the lateral winging generated by trapezius and rhomboid paralysis. Most cases of serratus anterior paralysis spontaneously resolve within 24 months, while conservative treatment of trapezius paralysis is less effective. A conservative course of treatment is usually followed for rhomboid paralysis. To allow time for spontaneous recovery, a 6–24 month course of conservative treatment is often recommended, after which if there is no recovery, patients become candidates for corrective surgery.

Clinical and arthroscopic findings in recreationally active patients

OBJECTIVE

To examine the diagnostic accuracy of standard clinical tests for the shoulder in recreational athletes with activity related pain.

DESIGN

Cohort study with index test of clinical examination and reference standard of arthroscopy.

SETTING

Sports Medicine clinic in Sheffield, U.K.

PARTICIPANTS

101 recreational athletes (82 male, 19 female; mean age 40.8 +/- 14.6 years) over a six year period.

INTERVENTIONS

Bilateral evaluation of movements of the shoulder followed by standardized shoulder tests, formulation of clinical diagnosis and shoulder arthroscopy conducted by the same surgeon.

MAIN OUTCOME MEASUREMENTS

Sensitivity, specificity, likelihood ratio for a positive test and over-all accuracy of clinical examination was examined retrospectively and compared with arthroscopy.

RESULTS

Isolated pathology was rare, most patients (72%) having more than one injury recorded. O'Brien's clinical test had a mediocre sensitivity (64%) and over-all accuracy (54%) for diagnosing SLAP lesions. Hawkins test and Jobe's test had the highest but still not impressive over-all accuracy (67%) and sensitivity (67%) for rotator cuff pathology respectively. External and internal impingement tests showed similar levels of accuracy. When a positive test was observed in one of a combination of shoulder tests used for diagnosing SLAP lesions or rotator cuff disease, sensitivity increased substantially whilst specificity decreased.

CONCLUSIONS

The diagnostic accuracy of isolated standard shoulder tests in recreational athletes was over-all very poor, potentially due to the majority of athletes (71%) having concomitant shoulder injuries. Most likely, this means that many of these injuries are missed in general practice and treatment is therefore delayed. Clinical examination of the shoulder should involve a combination of clinical tests in order to identify likely intra articular pathology which may warrant referral to specialist for surgery.

Industrial Medicine and Acute Musculoskeletal Rehabilitation. 6. Upper- and Lower-Limb Injections for Acute Musculoskeletal Injuries and Injured Workers

This self-directed study module focuses on the use of corticosteroids and other injections in the treatment of lateral epicondylitis, de Quervain's tenosynovitis, carpal tunnel syndrome, Achilles' tendinitis, and plantar fasciitis. It is part of the study guide on industrial rehabilitation medicine and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation.

OVERALL ARTICLE OBJECTIVE

To review the medical literature to help clinicians make treatment decisions regarding corticosteroid and other injections in the upper and lower limbs in injured workers.