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Picasso R, Pistoia F, Zaottini F, Marcenaro G, Miguel-Pérez M, Tagliafico AS, Martinoli C. Adhesive Capsulitis of the Shoulder: Current Concepts on the Diagnostic Work-Up and Evidence-Based Protocol for Radiological Evaluation. Diagnostics (Basel) 2023; 13:3410. [PMID: 37998547 PMCID: PMC10670865 DOI: 10.3390/diagnostics13223410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/28/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
Adhesive capsulitis is an idiopathic and disabling disorder characterized by intense shoulder pain and progressive limitation of active and passive glenohumeral joint range of motion. Although adhesive capsulitis has been traditionally considered a diagnosis of exclusion that can be established based on a suggestive medical history and the detection of supporting findings at the physical exam, imaging studies are commonly requested to confirm the diagnostic suspicion and to exclude other causes of shoulder pain. Indeed, clinical findings may be rather unspecific, and may overlap with diseases like calcific tendinitis, rotator cuff pathology, acromioclavicular or glenohumeral arthropathy, autoimmune disorders, and subacromial/subdeltoid bursitis. Magnetic resonance imaging, magnetic resonance arthrography, and high-resolution ultrasound have shown high sensitivity and accuracy in diagnosing adhesive capsulitis through the demonstration of specific pathological findings, including thickening of the joint capsule and of the coracohumeral ligament, fibrosis of the subcoracoid fat triangle, and extravasation of gadolinium outside the joint recesses. This narrative review provides an updated analysis of the current concepts on the role of imaging modalities in patients with adhesive capsulitis, with the final aim of proposing an evidence-based imaging protocol for the radiological evaluation of this condition.
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Affiliation(s)
- Riccardo Picasso
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16145 Genova, Liguria, Italy; (R.P.); (F.Z.); (A.S.T.); (C.M.)
| | - Federico Pistoia
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16145 Genova, Liguria, Italy; (R.P.); (F.Z.); (A.S.T.); (C.M.)
| | - Federico Zaottini
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16145 Genova, Liguria, Italy; (R.P.); (F.Z.); (A.S.T.); (C.M.)
| | - Giovanni Marcenaro
- Department of Health Sciences (DISSAL), Università di Genova, Via Antonio Pastore 1, 16132 Genova, Liguria, Italy;
| | - Maribel Miguel-Pérez
- Unidad de Anatomía y Embriología Humana, Departamento de Patología y Terapéutica Experimental, Facultad de Medicina y Ciencias de la Salud (Campus de Bellvitge), Universitat de Barcelona, 08904 Barcelona, Spain;
| | - Alberto Stefano Tagliafico
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16145 Genova, Liguria, Italy; (R.P.); (F.Z.); (A.S.T.); (C.M.)
- Department of Health Sciences (DISSAL), Università di Genova, Via Antonio Pastore 1, 16132 Genova, Liguria, Italy;
| | - Carlo Martinoli
- IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16145 Genova, Liguria, Italy; (R.P.); (F.Z.); (A.S.T.); (C.M.)
- Department of Health Sciences (DISSAL), Università di Genova, Via Antonio Pastore 1, 16132 Genova, Liguria, Italy;
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Yamamoto N, Szymski D, Voss A, Ishikawa H, Muraki T, Cunha RA, Ejnisman B, Noack J, McCarty E, Mulcahey MK, Itoi E. Non-operative management of shoulder osteoarthritis: Current concepts. J ISAKOS 2023; 8:289-295. [PMID: 37321293 DOI: 10.1016/j.jisako.2023.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/26/2023] [Accepted: 06/08/2023] [Indexed: 06/17/2023]
Abstract
Glenohumeral osteoarthritis (OA) is one of the most common causes of shoulder pain. Conservative treatment options include physical therapy, pharmacological therapy, and biological therapy. Patients with glenohumeral OA present shoulder pain and decreased shoulder range of motion (ROM). Abnormal scapular motion is also seen in patients as adaptation to the restricted glenohumeral motion. Physical therapy is performed to (1) decrease pain, (2) increase shoulder ROM, and (3) protect the glenohumeral joint. To decrease pain, it should be assessed whether the pain appears at rest or during shoulder motion. Physical therapy may be effective for motion pain rather than rest pain. To increase shoulder ROM, the soft tissues responsible for the ROM loss need to be identified and targeted for intervention. To protect the glenohumeral joint, rotator cuff strengthening exercises are recommended. Administration of pharmacological agents is the major part next to physical therapy in the conservative treatment. The main aim of pharmacological treatment is the reduction of pain and diminution of inflammation in the joint. To achieve this aim, non-steroidal anti-inflammatory drugs are recommended as first-line therapy. Additionally, the supplementation of oral vitamin C and vitamin D can help to slow down cartilage degeneration. Depending on the individual comorbidities and contraindications, sufficient medication with good pain reduction is thus possible for each patient. This interrupts the chronic inflammatory state in the joint and, in turn, enables pain-free physical therapy. Biologics such as platelet-rich plasma, bone marrow aspirate concentrate, and mesenchymal stem cells have gathered increased attention. Good clinical outcomes have been reported, but we need to be aware that these options are helpful in decreasing shoulder pain but neither stopping the progression nor improving OA. Further evidence of biologics needs to be obtained to determine their effectiveness. In athletes, a combined approach of activity modification and physical therapy can be effective. Oral medications can provide patients with transient pain relief. Intra-articular corticosteroid injection, which provides longer-term effects, must be used cautiously in athletes. There is mixed evidence for the efficacy of hyaluronic acid injections. There is still limited evidence regarding the use of biologics.
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Affiliation(s)
- Nobuyuki Yamamoto
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai 980-8574, Japan
| | - Dominik Szymski
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg 93053, Germany; Sporthopaedicum Regensburg, Regensburg 93053, Germany
| | - Andreas Voss
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg 93053, Germany; Sporthopaedicum Regensburg, Regensburg 93053, Germany
| | - Hiroaki Ishikawa
- Department of Physical Medicine and Rehabilitation, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Takayuki Muraki
- Department of Physical Medicine and Rehabilitation, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Ronaldo A Cunha
- Department of Sports Medicine, Federal University of São Paulo, São Paulo 05508-090, Brazil
| | - Benno Ejnisman
- Department of Sports Medicine, Federal University of São Paulo, São Paulo 05508-090, Brazil
| | - Joseph Noack
- Department of Orthopaedic Surgery, University of Colorado, CO 80309, USA
| | - Eric McCarty
- Department of Orthopaedic Surgery, University of Colorado, CO 80309, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, LA 70112, USA
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku Rosai Hospital, Sendai 981-8563, Japan.
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Kato T, Inui A, Mifune Y, Nishimoto H, Yoshikawa T, Shinohara I, Furukawa T, Tanaka S, Kusunose M, Kuroda R. Dynamic Analysis of the Coracohumeral Ligament Using Ultra-Sonography in Shoulder Contracture. SENSORS (BASEL, SWITZERLAND) 2023; 23:4015. [PMID: 37112354 PMCID: PMC10143514 DOI: 10.3390/s23084015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/09/2023] [Accepted: 04/14/2023] [Indexed: 06/19/2023]
Abstract
The coracohumeral ligament (CHL) is related to the range of motion of the shoulder joint. The evaluation of the CHL using ultrasonography (US) has been reported on the elastic modulus and thickness of the CHL, but no dynamic evaluation method has been established. We aimed to quantify the movement of the CHL by applying Particle Image Velocimetry (PIV), a technique used in the field of fluid engineering, to cases of shoulder contracture using the US. The subjects were eight patients, with 16 shoulders. The coracoid process was identified from the body surface, and a long-axis US image of the CHL parallel to the subscapularis tendon was drawn. The shoulder joint was moved from 0 degrees of internal/external rotation to 60 degrees of internal rotation at a rhythm of one reciprocation every 2 s. The velocity of the CHL movement was quantified by the PIV method. The mean magnitude velocity of CHL was significantly faster on the healthy side. The maximum magnitude velocity was significantly faster on the healthy side. The results suggest that the PIV method is helpful as a dynamic evaluation method, and in patients with shoulder contracture, the CHL velocity was significantly decreased.
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Affiliation(s)
| | - Atsuyuki Inui
- Correspondence: ; Tel.: +81-78-382-5111; Fax: +81-78-351-6944
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Stella SM, Gualtierotti R, Trentanni C, Ciampi B, Del Chiaro A, Galletti S. A Response to: Letter to the Editor Regarding Ultrasound Features of Adhesive Capsulitis. Rheumatol Ther 2022; 9:1225-1228. [PMID: 35575881 PMCID: PMC9314545 DOI: 10.1007/s40744-022-00451-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/06/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Salvatore Massimo Stella
- Advanced Musculoskeletal Ultrasound SIUMB School of Pisa, Department of Clinical and Experimental Medicine, Santa Chiara University Hospital, Pisa, Italy
| | - Roberta Gualtierotti
- Department of Pathophysiology and Transplantation, University of Milan Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Internal Medicine–Hemostasis and Thrombosis, Milan, Italy
| | - Cesare Trentanni
- Diagnostic Radiology Operational Unit, Carlo Poma Hospital, Mantua, Italy
- Advanced Musculoskeletal Ultrasound, SIUMB School of Pisa, Pisa, Italy
| | - Barbara Ciampi
- Advanced Musculoskeletal Ultrasound, SIUMB School of Pisa, Pisa, Italy
| | - Andrea Del Chiaro
- Advanced Musculoskeletal Ultrasound, SIUMB School of Pisa, Pisa, Italy
- Orthopedic and Traumatology Operating Unit, San Luca Hospital, Lucca, Italy
| | - Stefano Galletti
- Advanced Musculoskeletal Ultrasound, SIUMB School of Pisa, Pisa, Italy
- Advanced Musculoskeletal Ultrasound, SIUMB School of Bologna, Maggiore Hospital, Bologna, Italy
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Association of damage to the coracohumeral ligament with anterosuperior rotator cuff degeneration revealed by anatomical dissection. Sci Rep 2022; 12:4238. [PMID: 35273287 PMCID: PMC8913693 DOI: 10.1038/s41598-022-08070-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 03/02/2022] [Indexed: 11/08/2022] Open
Abstract
The coracohumeral ligament (CHL) is an important structure of the biceps pulley which also merges with the rotator cuff. Which role it actually plays in the pathogenesis of rotator cuff degeneration (RCD) and rotator cuff tears (RCT) is still a point of discussion. The hypothesis of this study was, that macroscopic injury to the anterosuperior part of the rotator cuff also includes parts of or the whole CHL. Forty fresh-frozen shoulders were dissected and examined, the morphology of the rotator cuff and the coracohumeral ligament were evaluated and existing lesions documented. 27.5% of the shoulder joints showed an anterosuperior full-thickness RCT. 57.5% of all examined shoulder girdles showed at least a partial rupture of the CHL. A highly significant correlation (p < 0.001, rho = 0.529) between the presence of rotator cuff tears and ruptures of the CHL was found. Cartilage damage within the anterosuperior section of the humeral head was observed in 20% cases. In rotator cuff degeneration and atraumatic rotator cuff tears of the elderly population, the pathomechanism of full-thickness RCT is based on repetitive anterosuperior glenoid impingement. This is especially supported by the identification of a higher frequency of CHL lesions compared to RCT reported in this study. No intact CHL was identified in shoulders with damaged rotator cuff tendons.
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Hagiwara Y, Kanazawa K, Ando A, Sekiguchi T, Yabe Y, Takahashi M, Koide M, Takahashi N, Sugaya H. Clinical outcomes of arthroscopic pan-capsular release with or without entire coracohumeral ligament release for patients with frozen shoulder. JSES Int 2020; 4:826-832. [PMID: 33345222 PMCID: PMC7738570 DOI: 10.1016/j.jseint.2020.08.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background We aimed to retrospectively determine the effects of arthroscopic pan-capsular release with or without entire coracohumeral ligament (CHL) release and diabetes mellitus (DM) in patients with frozen shoulder (FS). Methods The study included 34 patients (20 male and 14 female patients) who underwent arthroscopic pan-capsular release without entire CHL release (group 1) and 26 patients (6 male and 20 female patients) who underwent entire CHL release for FS (group 2). Patients with a minimum of 12 months of follow-up were included, and range of motion (ROM) and the shoulder rating scale of the University of California at Los Angeles (UCLA) scoring system were evaluated. Results In group 2, external rotation and hand-behind-the-back (HBB) ROMs were significantly increased compared with group 1 at the final follow-up (external rotation, 53.1° ± 15.2° vs. 41.3° ± 20.5° [P = .044]; HBB level, T6 [interquartile range, T5-T9] vs. T11 [interquartile range, T8-L4] [P < .001]). Total UCLA scores and UCLA scores for pain (9.2 ± 1.5 vs. 10.0, P = .003), function (8.5 ± 1.4 vs. 10.0, P < .001), and active forward flexion (4.6 ± 0.6 vs. 4.9 ± 0.2, P < .011) were significantly greater in group 2 at the final follow-up. Patients without DM tended to have greater recovery of forward flexion and HBB ROMs and better total, pain, and function UCLA scores compared with those with DM. In group 2, there were no significant differences in ROMs and UCLA scores between the patients with DM and those without DM. Conclusion Arthroscopic entire CHL release is an essential treatment option for FS patients to regain ROMs and function and to reduce pain.
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Affiliation(s)
- Yoshihiro Hagiwara
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Kenji Kanazawa
- Department of Orthopaedic Surgery, South Miyagi Medical Center, Ōgawara, Japan
| | - Akira Ando
- Department of Orthopaedic Surgery, Matsuda Hospital, Sendai, Japan
| | - Takuya Sekiguchi
- Department of Orthopaedic Surgery, Japan Railway Company Sendai Hospital, Sendai, Japan
| | - Yutaka Yabe
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Masaki Takahashi
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Masashi Koide
- Department of Orthopaedic Surgery, Matsuda Hospital, Sendai, Japan
| | - Norimasa Takahashi
- Department of Orthopaedic Surgery, Funabashi Orthopaedic Hospital, Funabashi, Japan
| | - Hiroyuki Sugaya
- Department of Orthopaedic Surgery, Funabashi Orthopaedic Hospital, Funabashi, Japan
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Hagiwara Y, Kanazawa K, Ando A, Sekiguchi T, Koide M, Yabe Y, Suzuki K, Itoi E. Effects of joint capsular release on range of motion in patients with frozen shoulder. J Shoulder Elbow Surg 2020; 29:1836-1842. [PMID: 32414610 DOI: 10.1016/j.jse.2020.01.085] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/11/2020] [Accepted: 01/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND A thickened joint capsule is believed to be one of the most specific manifestations of and the primary restraint against range of motion (ROM) in frozen shoulders. The purpose of this study was to evaluate the relationship among ROMs under general anesthesia before surgery and the effects of each joint capsular release on ROM. METHODS ROM was measured using a goniometer with scapular fixation. Arthroscopic pan-capsular release was performed with the patient in the beach-chair position in the following order: (1) rotator interval, (2) coracohumeral ligament, (3) superior capsule, (4) middle glenohumeral ligament, (5) anterior inferior glenohumeral ligament, and (6) posterior inferior glenohumeral ligament. ROMs in forward flexion (FF), lateral elevation (LE), external rotation with the arm at the side (ER1), external rotation at 90° of LE (ER2), internal rotation at 90° of LE (IR2), horizontal flexion, external rotation at 90° of FF (ER3), and internal rotation at 90° of FF (IR3) were evaluated before and after each release. RESULTS A total of 32 consecutive shoulders were included. After each capsular release, the ROM recovered; the final ROM was significantly greater on the affected side than on the unaffected side. Significant correlations were found between FF and LE, FF and ER1, ER1 and ER2, ER1 and ER3, ER2 and ER3, and IR2 and IR3 on both sides, regardless of surgery. CONCLUSION Each segment of the joint capsule affected ROM in all directions, supporting the need for whole-joint capsular release; ROM was significantly greater on the affected side than on the unaffected side after surgery.
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Affiliation(s)
- Yoshihiro Hagiwara
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan.
| | - Kenji Kanazawa
- Department of Orthopaedic Surgery, South Miyagi Medical Center, Ōgawara, Japan
| | - Akira Ando
- Department of Orthopaedic Surgery, Matsuda Hospital, Sendai, Japan
| | - Takuya Sekiguchi
- Department of Orthopaedic Surgery, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Masashi Koide
- Department of Orthopaedic Surgery, Matsuda Hospital, Sendai, Japan
| | - Yutaka Yabe
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Kazuaki Suzuki
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
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Yano T, Hagiwara Y, Ando A, Kanazawa K, Koide M, Sekiguchi T, Itaya N, Onoki T, Suzuki K, Tsuchiya M, Sogi Y, Yabe Y, Itoi E. RAGE-dependent NF-kB inflammation processes in the capsule of frozen shoulders. J Shoulder Elbow Surg 2020; 29:1884-1891. [PMID: 32279986 DOI: 10.1016/j.jse.2020.01.076] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/30/2019] [Accepted: 01/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The etiology of frozen shoulder (FS) remains uncertain. Advanced glycation end-products (AGEs) cause the cross-linking and stabilization of collagen and are increased in FS. The purpose of this study was to elucidate the pathogenesis of FS by evaluating the receptor of AGE (RAGE)-dependent pathways. METHODS Tissue samples of the coracohumeral ligament (CHL) and anterior inferior glenohumeral ligament (IGHL) were collected from 33 patients with FS, with severe stiffness, and 25 with rotator cuff tears (RCTs) as controls. Gene expression levels of RAGE, high-mobility group box 1 (HMGB1), Toll-like receptor 2 (TLR2), TLR4, nuclear factor-kappa B (NF-kB), and cytokines were evaluated using a quantitative real-time polymerase chain reaction. The immunoreactivities of carboxymethyllysine (CML), pentosidine, and RAGE were also evaluated. CML and pentosidine were further evaluated using high-performance liquid chromatography. RESULTS Gene expression levels of RAGE, HMGB1, TLR2, TLR4, and NF-kB were significantly greater in the CHLs and IGHLs from the FS group than in those from the RCT group. Immunoreactivities of RAGE and CML were stronger in the CHLs and IGHLs from the FS group than in those from the RCT group. Pentosidine was weakly immunostained in the CHLs and IGHLs from the FS group. CML using high-performance liquid chromatography was significantly greater in the CHLs and IGHLs from the FS group than in those from the RCT group. CONCLUSIONS AGEs and HMGB1 might play important roles in the pathogenesis of FS by binding to RAGE and activating NF-kB signaling pathways. Suppression of these pathways could be a treatment option for FS.
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Affiliation(s)
- Toshihisa Yano
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Yoshihiro Hagiwara
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan.
| | - Akira Ando
- Department of Orthopaedic Surgery, Matsuda Hospital, Sendai, Japan
| | - Kenji Kanazawa
- Department of Orthopaedic Surgery, South Miyagi Medical Center, Ogawara, Japan
| | - Masashi Koide
- Department of Orthopaedic Surgery, Matsuda Hospital, Sendai, Japan
| | - Takuya Sekiguchi
- Department of Orthopaedic Surgery, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Nobuyuki Itaya
- Department of Orthopaedic Surgery, Sendai Hospital of East Japan Railway Company, Sendai, Japan
| | - Takahiro Onoki
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Kazuaki Suzuki
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | | | - Yasuhito Sogi
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Yutaka Yabe
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
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Adidharma W, Lewis SP, Liu Y, Osorio MB, Steinman SE, Tse RW. Shoulder Release and Tendon Transfer following Neonatal Brachial Plexus Palsy: Gains, Losses, and Midline Function. Plast Reconstr Surg 2020; 146:321-331. [PMID: 32740582 DOI: 10.1097/prs.0000000000007037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Shoulder release and tendon transfer is frequently performed to address persistent weakness from neonatal brachial plexus palsy. Although postoperative improvements in motion are well described, associated deficits are poorly documented, and functional assessments are lacking. Loss of ability to reach midline can occur with surgery and may result in impairment. The purpose of this study was to comprehensively assess the gains, losses, functional changes, and patient-reported outcome associated with the authors' surgical approach. METHODS Consecutive patients undergoing surgery with 2-year follow-up were included (n = 30). Prospectively recorded assessments by therapists were reviewed. Changes were assessed by t test and Wilcoxon rank sum (p < 0.05). RESULTS Active external rotation and abduction improved and internal rotation diminished. Aggregate modified Mallet score increased with improvements in all subscales, except that hand to spine was unchanged and hand to belly decreased. Functional assessment using the Brachial Plexus Outcome Measure revealed an increase of aggregate score, with no decline in any subscales. Improvements were in hand to back of head, forward overhead reach, holds plate with palm up, opening large container, and strings bead. Aggregate patient self-report of appearance and function increased (from 18 to 23). Loss of ability to reach midline occurred in three patients (10 percent) who had extended Erb or total palsy and preoperative limitations of internal rotation. CONCLUSIONS Secondary reconstruction rebalances shoulder motion by increasing external rotation and abduction and reducing internal rotation. In this study, a conservative surgical approach results in overall improvement in task-based abilities and self-reported outcomes and preservation of internal rotation within a functional range. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Widya Adidharma
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Sarah P Lewis
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Yusha Liu
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Marisa B Osorio
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Suzanne E Steinman
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Raymond W Tse
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
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The effect of concomitant coracohumeral ligament release in arthroscopic rotator cuff repair to prevent postoperative stiffness: a retrospective comparative study. Knee Surg Sports Traumatol Arthrosc 2019; 27:3881-3889. [PMID: 30850882 DOI: 10.1007/s00167-019-05433-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 02/19/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE This study was to evaluate the efficacy and safety of coracohumeral ligament (CHL) release from the coracoid process concomitant with arthroscopic rotator cuff repair for preventing postoperative stiffness. METHODS Data on patients who underwent arthroscopic rotator cuff repair with a minimum follow-up of 1 year were collected retrospectively. Propensity score matching (1-to-1) was performed between a no-releasing group (Group I) and CHL-releasing group (Group II). In total, 76 patients in each group were matched. Clinical outcomes were assessed and compared between the two groups, including range of motion (ROM) and visual analogue scale for pain (pVAS) at postoperative 3 months, 6 months, and 1 year. The integrity of the repaired tendon was assessed at 1-year follow-up using either magnetic resonance imaging or ultrasonography. RESULTS External rotation (ER) at side at postoperative 3 months in Group II was better than that in Group I (48.6° ± 11.6° vs. 38.4° ± 13.0°, P < 0.001). When evaluating only patients with a small-to-medium sized tear at postoperative 3 months, ER at side was 49.8° ± 10.9° in Group II versus 37.8° ± 13.1° in Group I (P < 0.001). In patients with a large-to-massive sized tear, however, there was no significant difference in ER at side at postoperative 3 months (n.s.). There was no significant difference in ROM and functional scores at postoperative 6 months and 1 year, and there was no significant difference in healing failure rate (6 cases in Group I (7.9%), 2 cases in Group II (2.6%); n.s.). No complications of the CHL release procedure occurred. CONCLUSIONS In arthroscopic rotator cuff repair, CHL release from the coracoid process without creating a rotator interval defect could be an effective and safe method to prevent early postoperative stiffness, especially ER at side in patients with a small-to-medium sized tear. Therefore, CHL release can be used as a selective procedure to prevent postoperative stiffness in patients that may benefit from this procedure with decreased preoperative ER compared to the normal side. LEVEL OF EVIDENCE Level III.
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Hagiwara Y, Sekiguchi T, Ando A, Kanazawa K, Koide M, Hamada J, Yabe Y, Yoshida S, Itoi E. Effects of Arthroscopic Coracohumeral Ligament Release on Range of Motion for Patients with Frozen Shoulder. Open Orthop J 2018; 12:373-379. [PMID: 30288192 PMCID: PMC6151962 DOI: 10.2174/1874325001812010373] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/13/2018] [Accepted: 08/15/2018] [Indexed: 11/22/2022] Open
Abstract
Background: A thickened coracohumeral ligament is a highly specific manifestation of, and primary restraint against external rotation in frozen shoulders. Objective: The purpose of this study was to evaluate the effects of complete arthroscopic coracohumeral ligament release on range of motion in frozen shoulder. Methods: Fifty-two consecutive shoulders in 52 patients were treated between April 2015 and June 2016. To evaluate solely glenohumeral range of motion, the scapula was fixed by an examiner with one hand (without palpating scapular motion), and range of motion was measured using a goniometer. For the first step, arthroscopic pancapsular release was performed in a beach-chair position with (Group 1) or without (Group 2) complete coracohumeral ligament release. For the final step, the remaining coracohumeral ligaments in Group 2 were released and the ranges of motion were compared to those in Group 1. Results: The average age of the patients was significantly higher in Group 1, but there were no significant differences between the two groups with respect to sex, affected side, preoperative range of motion, or American Shoulder and Elbow Society Score. Abduction, external rotation at adduction, and external and internal rotations at 90° of flexion in Group 1 were significantly greater than those in Group 2. After the additional release of the remaining coracohumeral ligaments in Group 2, all ranges of motion were significantly recovered and there was no significant difference between the groups. Conclusion: Complete coracohumeral ligament release is a recommended intraoperative procedure for regaining full range of motion in frozen shoulders.
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Affiliation(s)
- Yoshihiro Hagiwara
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Japan
| | - Takuya Sekiguchi
- Department of Orthopaedic Surgery, Iwate Prefectural Centeral Hospital, Morioka, Japan
| | - Akira Ando
- Department of Otrhopaedic Surgery, Matsuda Hospital, Sendai, Japan
| | - Kenji Kanazawa
- Department of Otrhopaedic Surgery, South Miyagi Medical Center, Ohgawara, Japan
| | - Masashi Koide
- Department of Otrhopaedic Surgery, Matsuda Hospital, Sendai, Japan
| | - Junichiro Hamada
- Department of Orthopaedic Surgery, Kuwano Kyoritsu Hospital, Koriyama, Japan
| | - Yutaka Yabe
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Japan
| | - Shinichiro Yoshida
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Japan
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12
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Lee SH, Nam DJ, Kim SJ, Kim JW. Comparison of Clinical and Structural Outcomes by Subscapularis Tendon Status in Massive Rotator Cuff Tear. Am J Sports Med 2017; 45:2555-2562. [PMID: 28787191 DOI: 10.1177/0363546517721187] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The subscapularis tendon is essential in maintaining normal glenohumeral biomechanics. However, few studies have addressed the outcomes of tears extending to the subscapularis tendon in massive rotator cuff tears. PURPOSE To assess the clinical and structural outcomes of arthroscopic repair of massive rotator cuff tears involving the subscapularis. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Between January 2010 and January 2014, 122 consecutive patients with massive rotator cuff tear underwent arthroscopic rotator cuff repair. Overall, 122 patients were enrolled (mean age, 66 years; mean follow-up period, 39.5 months). Patients were categorized into 3 groups based on subscapularis tendon status: intact subscapularis tendon (I group; n = 45), tear involving less than the superior one-third (P group; n = 35), and tear involving more than one-third of the subscapularis tendon (C group; n = 42). All rotator cuff tears were repaired; however, subscapularis tendon tears involving less than the superior one-third in P group were only debrided. Pain visual analog scale, Constant, and American Shoulder and Elbow Surgeons scores and passive range of motion were measured preoperatively and at the final follow-up. Rotator cuff integrity, global fatty degeneration index, and occupation ratio were determined via magnetic resonance imaging preoperatively and 6 months postoperatively. RESULTS We identified 37 retears (31.1%) based on postoperative magnetic resonance imaging evaluation. Retear rate in patients in the C group (47.6%) was higher than that in the I group (22.9%) or P group (20.0%) ( P = .011). Retear subclassification based on the involved tendons showed that subsequent subscapularis tendon retears were noted in only the C group. The improvement in clinical scores after repair was statistically significant in all groups but not different among the groups. Between-group comparison showed significant differences in preoperative external rotation ( P = .021). However, no statistically significant difference was found in any shoulder range of motion measurements after surgery. CONCLUSION Arthroscopic repair of massive tears results in substantial improvements in shoulder function, despite the presence of combined subscapularis tears. However, this study showed a high failure rate of massive posterosuperior rotator cuff tear repair extending more than one-third of the subscapularis tendon. When combined subscapularis tendon tear was less than the superior one-third of the subscapularis tendon, arthroscopic debridement was a reasonable treatment method where comparable clinical and anatomic outcomes could be expected.
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Affiliation(s)
- Sung Hyun Lee
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Dae Jin Nam
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Se Jin Kim
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Jeong Woo Kim
- Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, Republic of Korea
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Baek S, Lee KJ, Kim K, Han SH, Lee UY, Lee KJ, Chung SG. High-Pressure Balloon-Assisted Stretching of the Coracohumeral Ligament to Determine the Optimal Stretching Positions: A Cadaveric Study. PM R 2016; 8:925-934. [PMID: 26972363 DOI: 10.1016/j.pmrj.2016.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 02/12/2016] [Accepted: 02/29/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The coracohumeral ligament (CHL) is a thick capsular structure and markedly thickened when affected by adhesive capsulitis. Therapeutic stretching is the most commonly applied treatment for adhesive capsulitis, but optimal stretching postures for maximal therapeutic effects on the CHL have not been fully investigated. OBJECTIVE To investigate the most effective stretching direction for the CHL by measuring the stretching intensity in 5 different directions and to determine whether the stretching intervention resulted in loosening of the ligament by comparing the changes of CHL tightness before and after stretching. DESIGN Biomechanical cadaver study. SETTING Academic institution cadaver laboratory. PARTICIPANTS Nine fresh frozen cadaveric shoulders. METHODS A high-pressure balloon catheter inserted under the CHL and intraballoon pressure was measured, to evaluate CHL tightness without ligament damage as well as to augment and monitor stretching intensity. To find the optimal stretching direction, the glenohumeral joint was stretched from the neutral position into 5 directions sequentially under pressure-monitoring: flexion, extension [EX], external rotation [ER], EX+ER, and EX+ER+adduction [AD] directions. MAIN OUTCOME MEASUREMENTS CHL tightness was determined by a surrogate parameter, the additional pressure created by the overlying CHL. The pressure increase (ΔPstr) by a specific directional stretch was considered as the stretching intensity. RESULTS ΔPstr by the 5 directions were mean (standard deviation) values of 0.03 ± 0.07 atm, 0.87 ± 1.31 atm, 1.13 ± 1.36 atm, 1.49 ± 1.32 atm, and 2.10 ± 1.70 atm, respectively, revealing the highest ΔPstr by the EX+ER+AD stretch (P < .05). The balloon pressure by the overlying CHL was decreased from 0.45 ± 0.35 atm to 0.18 ± 0.14 atm (P = .012) before and after the stretching manipulation. CONCLUSIONS EX+ER+AD of the glenohumeral joint resulted in the greatest increase in balloon pressure, implying that it could be the most effective stretching direction. A series of stretching manipulations assisted with an underlying pressure balloon were capable of decreasing CHL tightness. With further development and modification, high-pressure balloon-assisted stretching can be a potential therapeutic option to release tight CHL, including the advantage of augmenting and monitoring stretching intensity. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Sora Baek
- Department of Rehabilitation Medicine, School of Medicine, Kangwon National University, Chuncheon, South Korea
| | - Kyu Jin Lee
- Creta Laboratory, Creta Co Ltd, Seoul, Korea
| | - Keewon Kim
- Department of Rehabilitation Medicine and Department of Biomedical Engineering, College of Medicine, Seoul National University, Seoul, South Korea
| | - Seung-Ho Han
- Department of Anatomy, College of Medicine, Chung Ang University, Seoul, South Korea
| | - U-Young Lee
- Catholic Institute for Applied Anatomy, Department of Anatomy, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kun-Jai Lee
- Department of Rehabilitation Medicine, School of Medicine, Kangwon National University, Chuncheon, South Korea
| | - Sun Gun Chung
- Department of Rehabilitation Medicine, College of Medicine, Seoul National University, Seoul, South Korea; Rheumatism Research Institute, Medical Research Center, Seoul National University, Seoul, South Korea; Institute of Aging, Seoul National University, Seoul, South Korea; Seoul National University Hospital, Suite 12327, 101 Daehak-Ro Jongno-Gu, Seoul 03080, Korea
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Otsuka M, Ito T, Honjo T, Isaka T. Scapula behavior associates with fast sprinting in first accelerated running. SPRINGERPLUS 2016; 5:682. [PMID: 27350917 PMCID: PMC4899390 DOI: 10.1186/s40064-016-2291-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 05/05/2016] [Indexed: 11/10/2022]
Abstract
The arm-swing motion is important for coordinated lower limb movement during a fast sprint and is composed of three-dimensional scapulothoracic and glenohumeral joint motion. Here, we aimed to clarify the role of the scapula during the initiation of a sprint running when sprinter run with high horizontal acceleration. Ten sports-active students participated in four 5-m dashes, with scapular constraint using non-elastic therapy tape (constraint condition) and without scapular constraint (free condition). The sprinting kinematics was assessed by a 16-camera motion capture system. In the constraint condition, the 2-m sprint time was significantly longer than that in the free condition. At the instants of foot-contact and take-off during the first step, no significant difference in the humerothoracic flexion angle was seen between these two conditions. In contrast, at the instants of foot-contact and take-off during the first step, the humerothoracic extension angle in the constraint condition was significantly smaller than that in the free condition. The forward leaning vector angle of center of mass during the first step was significantly greater than that in the constraint condition. Although no significant difference in hip extension and foot forward leaning angles was seen at the instant of foot contact during the first step between the two conditions, at the instant of take-off, the hip extension and foot forward leaning angles in the constraint condition were significantly smaller than those in the free condition. Therefore, scapular behavior in first accelerated running contributes to larger upper- and lower-limb motions and facilitates coordinating whole-body balance for a fast sprint.
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Affiliation(s)
- Mitsuo Otsuka
- Faculty of Sport and Health Science, Ritsumeikan University, 1-1-1, Nojihigashi, Kusatsu-shi, Shiga 525-8577 Japan
| | - Taisuke Ito
- PT Medical Center, 4-10-3, Roppongi, Minato-ku, Tokyo, 106-0032 Japan
| | - Toyoyuki Honjo
- Department of Mechanical Systems Engineering, National Defense Academy School of Systems Engineering, 1-10-20 Hashirimizu, Yokosuka, Kanagawa 239-8686 Japan
| | - Tadao Isaka
- Faculty of Sport and Health Science, Ritsumeikan University, 1-1-1, Nojihigashi, Kusatsu-shi, Shiga 525-8577 Japan
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A Thickened Coracohumeral Ligament and Superomedial Capsule Limit Internal Rotation of the Shoulder Joint: Report of Three Cases. Case Rep Orthop 2016; 2016:9384974. [PMID: 27123353 PMCID: PMC4829705 DOI: 10.1155/2016/9384974] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 03/20/2016] [Indexed: 11/18/2022] Open
Abstract
Adhesive capsulitis of the shoulder (also known as frozen shoulder) is a painful and disabling disorder with an estimated prevalence ranging from 2% to 5% in the general population. Although the precise pathogenesis of frozen shoulder is unclear, thickened capsule and coracohumeral ligament (CHL) have been documented to be one of the most specific manifestations. The thickened CHL has been understood to limit external rotation of the shoulder, and restriction of internal rotation of the shoulder has been believed to be related to posterior capsular tightness. In this paper, three cases of refractory frozen shoulder treated through arthroscopic release of a contracted capsule including CHL were reported. Two cases in which there is recalcitrant severe restriction of internal rotation after manipulation under anesthesia (MUA) were finally treated with arthroscopic surgery. Although MUA could release the posterior capsule, internal rotation did not improve in our cases. After release of the thickened CHL, range of motion of internal rotation was significantly improved. This report demonstrates the role of the thickened CHL in limiting the internal rotation of the shoulder. We highlight the importance of release of thickened CHL in addition to the pancapsular release, in case of severe limitation of internal rotation of shoulder.
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Park JY, Chung SW, Lee SJ, Cho HW, Lee JH, Lee JH, Oh KS. Combined Subscapularis Tears in Massive Posterosuperior Rotator Cuff Tears: Do They Affect Postoperative Shoulder Function and Rotator Cuff Integrity? Am J Sports Med 2016; 44:183-90. [PMID: 26564791 DOI: 10.1177/0363546515610552] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies on massive rotator cuff tears have not addressed the outcomes of tears extending to the subscapularis tendon. HYPOTHESIS The retear rate in patients with a massive posterosuperior rotator cuff tear combined with a subscapularis tear is higher than that in patients with a massive posterosuperior rotator cuff tear with an intact subscapularis tendon. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Data were collected and analyzed from 92 consecutive patients who underwent arthroscopic repair of a massive posterosuperior rotator cuff tear. Patients were divided into 3 groups according to the status of the subscapularis tendon: intact subscapularis tendon (I-massive tear; n = 42), tear involving half or less than half of the subscapularis tendon (S-massive tear; n = 22), and tear involving more than half of the subscapularis tendon (L-massive tear; n = 28). The integrity of the rotator cuff was determined by ultrasonography at 4.5 and 12 months or later after surgery. Clinical evaluations were performed using the visual analog scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, the Constant score, and active shoulder range of motion. Data were collected on the day before surgery and at final follow-up (at least 24 months postoperatively). RESULTS A total of 25 retears (27%) were identified based on an ultrasonographic evaluation. Although statistical significance was not found, there was a trend toward a higher retear rate in patients with an L-massive tear (43%) compared with those with an S-massive tear (18%; P = .050) or I-massive tear (21%; P = .059) at final follow-up. The subclassification of retears according to the involved tendons revealed that subsequent retears of the subscapularis tendon were noted only in patients with an L-massive tear. In patients with an L-massive tear, postoperative data comparison between patients with intact subscapularis tendons and those with failed subscapularis tendons revealed that a significant difference was noted in the VAS (1.1 vs 3.8, respectively) and ASES (90.6 vs 58.5, respectively) scores. The improvement in clinical scores after repair was statistically significant in all groups but not different between the groups. CONCLUSION The arthroscopic repair of massive tears results in substantial improvements in shoulder function, regardless of the presence of combined subscapularis tears. However, this study showed a trend toward a high failure rate for the repair of massive posterosuperior rotator cuff tears extending over half of the subscapularis tendon. Therefore, other treatment options should also be considered for this type of rotator cuff tear.
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Affiliation(s)
| | - Seok Won Chung
- Konkuk University School of Medicine, Seoul, South Korea
| | | | | | | | - Jun-Hee Lee
- Konkuk University School of Medicine, Seoul, South Korea
| | - Kyung-Soo Oh
- Konkuk University School of Medicine, Seoul, South Korea
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Hidaka E, Aoki M, Izumi T, Suzuki D, Fujimiya M. Ligament strain on the iliofemoral, pubofemoral, and ischiofemoral ligaments in cadaver specimens: Biomechanical measurement and anatomical observation. Clin Anat 2014; 27:1068-75. [DOI: 10.1002/ca.22425] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 05/08/2014] [Accepted: 05/14/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Egi Hidaka
- The 2nd Department of Anatomy; Graduate School of Medicine; Sapporo Medical University; Sapporo Japan
| | - Mitsuhiro Aoki
- Department of Orthopedics; Health Science University of Hokkaido School of Rehabilitation Sciences; Ishikari Japan
| | - Tomoki Izumi
- The Department of Physical Therapy; Graduate School of Health Sciences; Sapporo Medical University; Sapporo Japan
| | - Daisuke Suzuki
- The 2nd Department of Anatomy; School of Medicine; Sapporo Medical University; Sapporo Japan
| | - Mineko Fujimiya
- The 2nd Department of Anatomy; School of Medicine; Sapporo Medical University; Sapporo Japan
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Donatelli R, Ruivo R, Thurner M, Ibrahim MI. New concepts in restoring shoulder elevation in a stiff and painful shoulder patient. Phys Ther Sport 2014; 15:3-14. [DOI: 10.1016/j.ptsp.2013.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 10/31/2013] [Accepted: 11/01/2013] [Indexed: 10/26/2022]
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