Diagnostic values of tests for acromioclavicular joint pain

A systematic review of the treatment of primary acromioclavicular joint osteoarthritis

Background

This systematic review aims to comprehensively summarise and present the available evidence for the treatment of primary acromioclavicular joint (ACJ) osteoarthritis (OA).

Methods

Five databases were searched for studies investigating the management of ACJ OA. Included were studies with participants with clinical/radiological signs of primary ACJ OA, an intervention and included a functional outcome measure.

Results

Forty-eight studies were included. Treatments consisted of physiotherapy (n = 1 study), medical only (n = 11) and operative management (n = 36). Operative studies included five comparative trials - physiotherapy versus surgery (n = 1) and open versus arthroscopic resection (n = 4). A total of 1902 shoulders were treated for ACJ OA, mean age (51 years), 58% male and mean follow-up (28.5 months). Treatment with injection showed a mean improvement of 50% in pain levels at follow-up (mean = 7.5 months). The commonest surgical procedure was arthroscopic excision of the distal clavicle and operative studies averaged 6 months of conservative management and a mean functional outcome of 87.8%.

Conclusion

Studies varied in indication, intervention and quality but it did not provide evidence that both non-operative and operative interventions are effective. There was no significant difference between open or arthroscopic distal clavicle excision (DCE). Participants having between 0.5 and 2 cm of clavicle excised had good outcomes and those requiring concomitant shoulder procedures had similarly good outcomes.

Bone marrow edema in the acromioclavicular joint after arthroscopic rotator cuff repair

BACKGROUND

Bone marrow edema (BME) in the acromioclavicular joint (ACj) may occur after arthroscopic rotator cuff repair (ARCR), resulting in persistent postoperative ACj pain. We investigated the incidence and clinical characteristics of BME in ACj after ARCR.

METHODS

Patients exhibiting ACj-related symptoms prior to ARCR surgery, no BME in the ACj on MRI, and an ability to undergo 2-year postoperative physical and MRI examinations of the ACj were included. Patients who underwent distal clavicle resection or osteophyte resection below the ACj and those unable to achieve primary repair of the rotator cuff were excluded. MRI evaluation was performed preoperatively and at 3, 6, 12, and 24 months postoperatively. Patients who showed BME in ACj on fat-suppressed T2 MRI at 24 months postoperatively were classified into the BME + group, and those with no BME were classified into the BME- group. Patient background, operation time, Japanese Orthopedic Association (JOA) score, re-tear rate, ACj tenderness, and cross-body adduction test were compared between groups. In addition, we examined the time of occurrence of BME.

RESULTS

A total of 345 ARCRs were performed during the study period. After the exclusion of 114 shoulders, the remaining 231 shoulders were included in this study. There were 208 cases in the BME- group and 23 cases in the BME + group. The incidence of BME was 9.96 %. Although the JOA scores of both groups showed a significant improvement postoperatively compared to preoperatively, there was no significant difference between the two groups. In terms of re-tear, there was 1 case in the BME + group and 7 in the BME- group. Positive ACj tenderness and cross-body adduction test were significantly higher in the BME + group (P < 0.001). BME occurred in 6 cases at 3 months, 9 cases at 6 months, and 8 cases at 1 year postoperatively. None of the patients developed BME at more than 1 year postoperatively. BME was observed on MRI in all cases at 2 years postoperatively.

CONCLUSIONS

The rate of occurrence of BME in the ACj after ARCR was 9.96 %. Patients with BME were significantly more likely to have ACj tenderness and positive cross-body adduction test. BME in the ACj often occurs within 6 months to 1 year after ARCR of small-to-medium rotator cuff tears, suggesting a relationship with postoperative functional improvement of the shoulder joint. The ACj should be considered as a potential site of persistent pain after ARCR for small-to-medium rotator cuff tears.

Mid- to long-term success rate and functional outcomes of acromioclavicular injections in patients with acromioclavicular osteoarthritis

BACKGROUND

Acromioclavicular (AC) osteoarthritis (OA) is a frequent pathology of the shoulder in elderly patients. Drug injection plays an important role in treatment of AC OA. Literature has demonstrated excellent short-term results regarding shoulder function and pain. However, mid- to long-term results are lacking. The aim of this study was to assess the efficacy of a single intra-articular AC injection in patients with AC OA and to identify predictive factors for success.

METHODS

A retrospective study was performed to analyze success rate, shoulder function, and pain perception after a single intra-articular injection in patients with AC OA. Success was defined as the absence of reinterventions such as additional injection or surgery. Outcome measures were 1-year success rate and clinical outcome scores of Numeric Rating Scale (NRS) for pain, Oxford Shoulder Score, and Subjective Shoulder Value.

RESULTS

Ninety-eight patients participated in this study. At a median final follow-up of 0.8 years (interquartile range, 0-6), 57 of these patients (58%) had undergone a reintervention. The 1-year success rate was 47% (95% confidence interval, 37%-57%), with NRS at rest as the sole factor significantly associated with success. Thirty patients not requiring reintervention reported significant improvement from baseline for all reported outcome measures at final follow-up.

CONCLUSIONS

AC injections offer a 1-year success rate of 47%. The AC injection produces good mid- to long-term clinical outcomes regarding shoulder function, quality of life, and pain perception in one-third of patients. Further research is essential to analyze mid- to longterm outcomes of AC injections. Level of evidence: Level IV.

Acromioclavicular joint injuries revisited: Pathoanatomy, pathomechanics, and clinical presentation

Multiple papers have described aspects of treatment of acromioclavicular (AC) joint injuries. Most have emphasized aspects of surgical treatment, and some papers have addressed non-operative treatment. Few papers have highlighted the specific pathoanatomy of an AC joint injury or have described methods of evaluating the 3-dimensional pathomechanics resulting from the pathoanatomical injury. This paper is based on 3 observations: (1) AC joint injuries exist and present on a spectrum of pathoanatomy; (2) The effect of the pathoanatomy on normal AC joint mechanics to produce pathomechanics is dependent on the extent of the pathoanatomy; and (3) Treatment protocols should be developed to address the specific pathoanatomy to optimize the mechanics. A comprehensive clinical approach emphasizing the evaluation of the extent of the anatomic injury and understanding its mechanical consequences regarding shoulder and arm function is a key in the development of guidelines for developing operative or non-operative treatment protocols and for establishing outcomes of the treatment protocols.

Prediction of Bilaterality in Patients With 1 Posterosuperior Rotator Cuff Tear

BACKGROUND

In patients with a known unilateral posterosuperior rotator cuff tear (PSRCT), the ability to predict a contralateral PSRCT may assist in earlier diagnosis and improved patient outcomes.

PURPOSE

To determine factors associated with bilateral PSRCT and their most predictive combinations using a nonhospitalized general population.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

This study involved 736 individuals (n = 1472 shoulders) drawn from a rural cohort. PSRCT was diagnosed using magnetic resonance imaging. Symptoms of the contralateral shoulder were not considered. The demographic, physical, social, metabolic, and imaging factors, as well as comorbidities, were evaluated using logistic regression analysis. Cutoff values for the significantly associated variables obtained from multivariable logistic regression analysis were calculated using the receiver operating characteristic (ROC) curve. The areas under the ROC curve (AUCs) of the combinations of significantly associated variables were compared using the DeLong method to determine the combination most predictive of bilateral PSRCT. The likelihood ratio and the posttest probability for each of the combinations were assessed.

RESULTS

Age ≥61 years, manual labor, critical shoulder angle (CSA) ≥35°, retraction degree of Patte ≥ grade 2, biceps tendon injury, and metabolic syndrome were significantly associated with bilateral PSRCT in multivariable analysis (P < .001). The 1-by-1 combination of any 4 of the 6 associated factors significantly increased the AUC of any smaller combinations of those 6 factors (P < .001). The AUCs of the 4-somes were all similar (P ≥ .383) and were not significantly increased by further addition of identified associated factors (P ≥ .422). Any combination of 4 of the 6 associated factors was highly predictive of bilateral PSRCT, each having a minimum AUC of 0.70, a likelihood ratio of >10, and a minimum posttest probability of 80%.

CONCLUSION

Unilateral PSRCT, accompanied by any 4 of the variables of age ≥61 years, manual labor, CSA ≥35°, retraction degree of Patte ≥ grade 2, biceps tendon injury, and metabolic syndrome, is highly predictive of PSRCT in the other shoulder.

The acromioclavicular joint injuries treatment

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Increased T2 signal intensity in the distal clavicle does not justify acromioclavicular resection arthroplasty during rotator cuff repair

INTRODUCTION

Acromioclavicular (AC) arthropathy can contribute to shoulder pain; it can be treated surgically by distal clavicle resection (DCR). The aim of this study was to determine whether increased T2 signal intensity in the clavicle on MRI is an argument in favour of AC resection arthroplasty by DCR during rotator cuff repair.

METHODS

The MRI images from 107 shoulders in 107 patients were analysed. We looked for statistical relationships and correlations between shoulders with T2 hyperintensity (HI+) and those without (HI-) before surgery and then in shoulders with T2 hyperintensity (HI+) that underwent AC resection arthroplasty (AC+) and those who did not (AC-).

RESULTS

On MRI, T2 hyperintensity in the AC joint was correlated with sex (more often found in men) and radiological signs of AC arthropathy. There was no statistical correlation before surgery, particularly with AC pain, or after surgery, with outcomes in shoulders undergoing DCR.

CONCLUSION

When repairing rotator cuff tears, the presence of T2 hyperintensity on MRI in the distal clavicle is not a predictor of better clinical outcomes after AC resection arthroplasty is done. The AC pain may be related to the rotator cuff tear instead.

LEVEL OF EVIDENCE

II, prospective randomised study.

Benefits of distal clavicle resection during rotator cuff repair: Prospective randomized single-blind study

INTRODUCTION

Rotator cuff tears often occur in combination with acromioclavicular (AC) arthropathy. But it can be difficult to separate pain caused by the rotator cuff tear from pain caused by the AC joint, despite clinical and other examinations. Distal clavicle resection (DCR) is increasingly being done at the same time as arthroscopic rotator cuff repair. The aim of this study was to compare the functional outcomes 1 year after arthroscopic rotator cuff repair between patients who simultaneously undergo DCR and patients who do not. The primary hypothesis was that DCR improves the clinical outcomes.

MATERIAL AND METHODS

This was a prospective, multicenter, randomized, single-blind study of 200 patients who underwent isolated supraspinatus repair using the same technique. The patients were randomized into two groups: 97 patients who also underwent DCR and 103 patients who did not. The patients were followed until 1 year postoperative according to a standardized radiological and clinical review protocol.

RESULTS

At 1 year postoperative, all the clinical outcomes were worse in the DCR group, although only external rotation with elbow at side (53° vs. 59°, p=0.04) and the SSV (86.5 vs. 90.1, p=0.04) were statistically different. Overall shoulder pain was higher in the DCR group during the first 3 months postoperative (p=0.04). At 1 year, the DCR group had more residual pain; this pain was mainly located on the superior side of the shoulder (p=0.03), especially when more than 11 mm was resected (p=0.01). More of the shoulders in the DCR group had failures in rotator cuff healing based on ultrasonography (p=0.5).

CONCLUSION

Our hypothesis was not confirmed. We do not recommend doing routine DCR with arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

I, prospective randomized simple blind study.

The Virtual Shoulder and Knee Physical Examination

The COVID-19 crisis has forced a sudden and dramatic shift in the way that clinicians interact with their patients, from outpatient encounters to telehealth visits utilizing a variety of internet-based videoconferencing applications. Although many aspects of pre–COVID-19 outpatient sports medicine care will ultimately resume, it is likely that telehealth will persist because of its practicality and because of patient demand for access to efficient and convenient health care. Physical examination is widely considered a critical obstacle to a thorough evaluation of sports medicine patients during telehealth visits. However, a closer reflection suggests that a majority of the examination maneuvers are possible virtually with limited, if any, modifications. Thus, we provide a comprehensive shoulder and knee physical examination for sports medicine telehealth visits, including (1) verbal instructions in layman’s terms that can be provided to the patient before or read verbatim during the visit, (2) multimedia options (narrated videos and annotated presentations) of the shoulder and knee examination that can be provided to patients via screen-share options, and (3) a corresponding checklist to aid in documentation.

The Relationship Between the Clinical and Radiological Findings and the Outcomes of Early Surgical Treatment After Tossy Type III Acromioclavicular Joint Dislocation

Background

Acromioclavicular joint (ACJ) dislocation is a common injury among young and physically active persons. Evaluating surgical outcomes clinically and radiographically is widely accepted, but it is not known which clinical tests or radiological indicators are the most important. Our hypothesis is that there is a significant correlation between clinical and radiological findings and outcomes after the early surgical treatment of Tossy type III ACJ dislocation. 

Materials and methods

A retrospective study was conducted on 23 patients who underwent early surgical treatment after Tossy type III ACJ dislocation. We used the constant score (CS) and the simple shoulder test (SST) to measure the outcomes. For clinical evaluation, Paxinos, O’Brien’s, Bell-van Riet’s, and horizontal adduction tests were used. Standard A-P view radiographs were evaluated for redislocation, ACJ arthrosis, coracoclavicular (CC) space ossification, and for the presence of osteolysis.

Results

The mean time of follow-up was 16 months (range, 12-22 months). During the follow-up, all patients had one or more pathological radiological signs. All clinical tests were negative in 12 patients, seven had one positive test, three had two positive tests, and one had three positive tests. The mean CS result at the follow-up was 93.44 ± 4.90 (range, 84-100), and the mean SST result was 10.78 ± 1.51 (range, 6-12). There was no statistically significant association between the CS results and either shoulder tests or radiological findings. The SST results were statistically significantly lower for patients with positive O’Brien’s test compared to those with a negative one. In contrast, the SST results were statistically significantly higher for patients with CC space ossification, compared to those who did not have this radiological sign. Other clinical tests and radiological findings did not have any associations with the SST results.

Conclusions

We found that positive O’Brien’s test was associated with worse outcomes of early surgical treatment after Tossy type III ACJ dislocation. Despite the presence of pathological radiological signs, patients may have good or even perfect clinical outcomes after the early surgical treatment of a Tossy type III injury.

Current evidence for nonpharmacological interventions and criteria for surgical management of persistent acromioclavicular joint osteoarthritis: A systematic review

BACKGROUND

The primary aim of this systematic review was to investigate the individual/combined effectiveness of nonpharmacological interventions in individuals with persistent acromioclavicular joint osteoarthritis. The secondary aims were to investigate the comparative effectiveness of nonpharmacological versus surgical interventions, and to identify the criteria used for defining failure of conservative interventions in individuals who require surgery for persistent acromioclavicular joint osteoarthritis.

METHOD

Major electronic databases were searched from inception until October 2018. Studies involving adults aged 16 years and older, diagnosed clinically and radiologically with isolated acromioclavicular joint osteoarthritis for at least three months or more were included. Studies must explicitly state the type and duration of conservative interventions. Methodological risk of bias was assessed using the Modified Downs and Black checklist.

RESULTS

Ten surgical intervention studies were included for final synthesis. No studies investigated the effectiveness of nonpharmacological interventions or compared them with surgical interventions. Common nonpharmacological interventions trialed from the 10 included studies were activity modification (n = 8) and physiotherapy (n = 4). Four to six months was the most often reported timeframe defining failure of conservative management (range 3-12 months).

CONCLUSIONS

Currently, there is no evidence to guide clinicians about the individual or combined effectiveness of nonpharmacological interventions for individuals with persistent acromioclavicular joint osteoarthritis.

Association of high sensitivity C-reactive protein with tearing of the long head of the biceps tendon

Background

This study proposed to investigate whether high-sensitivity C-reactive protein (hs-CRP) is an independent risk factor for long head of biceps tendon (LHBT) tear and whether hs-CRP can increase accuracy in diagnosing LHBT tear.

Methods

This study involved 582 shoulders of 557 consecutive patients who received arthroscopic examinations at the authors’ institution between January 2010 and July 2018. The strengths of associations between LHBT tear and various factors were determined by calculating the odds ratios (ORs), with 95% confidence intervals (CIs), using logistic regression analyses. The studied variables were demographic, physical, social, metabolic, comorbidity, hs-CRP, and pain on a visual analog scale (VAS) factors, as well as those related to rotator cuff tear (RCT). Significant factors in the multivariable logistic analysis were evaluated to determine their diagnostic values, including their likelihood ratios and post-test probabilities for LHBT tear.

Results

In the multivariable analysis, five variables were significant: age, retraction degree of Patte, subscapularis tendon tear, hs-CRP > 1 mg/L, and pain VAS (p ≤ 0.01). The best combination of determinations for diagnosing LHBT tear, which yielded a strong positive likelihood ratio of 19.07 and a high post-test probability of 96%, was age ≥ 67 years, subscapularis tendon tear, grade of Patte ≥2, hs-CRP > 1, and pain VAS ≥ 7.

Conclusions

Serum hs-CRP > 1 mg/L is an independent risk factor for LHBT tear, along with the expected risk factors of age, subscapularis tendon tear, retraction degree of Patte, and pain VAS. Serum hs-CRP > 1 mg/L increases the diagnostic accuracy for LHBT tear.

Level of evidence

Level IV, Clinical case series.

Sports-related acute shoulder injuries in an urban population

Objectives

More than a third of sports injuries involve the upper extremity. The primary aim was to quantify and describe sports-related shoulder injuries in a general population cohort. A secondary aim was to compare aspects of these injuries to those that were not sports-related.

Methods

We performed a prospective registration of the activity at the time of shoulder injury in all cases admitted during 1 year in a combined primary care and orthopaedic emergency department serving a defined population. The electronic patient records and patient reported questionnaires were reviewed.

Results

Twenty-nine per cent (n=781) of 2650 registered shoulder injuries were reported to be sports-related, with the highest proportion in acromioclavicular injuries (>50%). Patients with sports injuries were younger than those injured during other activities (median age 28 and 43 years, respectively, p<0.001), and more often male (78% and 52%, respectively, p<0.001). There was a strong gender disparity in incidence of sports-related shoulder injuries in adolescents and young adults, which was not observed in non-sports shoulder injuries. Football (soccer) (6–29 years), cycling (30–49 years), skiing (50–69 years) and martial arts were the dominating sports activities. Fractures were more common in skiing and cycling than in other major sports in the study.

Conclusions

Almost a third of the shoulder injuries occurred during sports. The types of sports involved varied with age and gender. The comparison of sport to non-sport shoulder injury incidence rates suggests that the increased risk of shoulder injuries in young males is mainly attributable to sports injuries.

Comprehensive Review of Provocative and Instability Physical Examination Tests of the Shoulder

A detailed physical examination of the shoulder is crucial in creating a diagnosis in patients who present with shoulder pain. Tests of the cervical spine, scapula, and rotator cuff muscles have already been evaluated in a previous article. This article assesses provocative and instability examination tests of the shoulder. Descriptions on how the tests are performed and their diagnostic accuracy are presented.

Acromioclavicular joint injuries in overhead athletes: a concise review of injury mechanisms, treatment options, and outcomes

PURPOSE OF THE REVIEW

To review the relevant literature surrounding acromioclavicular (AC) joint injuries particularly pertaining to overhead athletes.

RECENT FINDINGS

The AC joint is a unique anatomic and biomechanical portion of the shoulder that can be problematic for athletes, particularly throwers, when injured. Treatment of these injuries remains a topic in evolution. Low-grade injuries (Rockwood types I & II) are typically treated non-operatively while high-grade injuries (types IV, V, and VI) are considered unstable and often require operative intervention. Type III AC separations remain the most controversial and challenging as no clear treatment algorithm has been established. A wide variety of surgical techniques exist. Unfortunately, relatively little literature exists with regard to overhead athletes specifically. Treatment of AC joint injuries remains challenging, at times, particularly for overhead athletes. Operative indications and techniques are still evolving, and more research is needed specifically surrounding overhead athletes.

Magnetic resonance imaging scans are not a reliable tool for predicting symptomatic acromioclavicular arthritis

BACKGROUND

We investigated whether magnetic resonance imaging (MRI) scans can accurately diagnose arthritis of the acromioclavicular joint (ACJ) because it has recently been suggested that bone marrow oedema on MRI scans is a predictive sign of symptomatic ACJ arthritis.

METHODS

The MRI scans of 43 patients (50 shoulders) who underwent ACJ excision for clinically symptomatic ACJ arthritis were compared to a control group of 43 age- and sex-matched patients (48 shoulders) who underwent an MRI scan for investigation of shoulder pain but did not have clinical symptoms or signs of ACJ arthritis. The scans were evaluated by an experienced musculoskeletal radiologist, who was blinded to the examination findings.

RESULTS

Bone marrow oedema was present in only 15 (30%) shoulders in the ACJ excision group, although this was higher than the six shoulders in the asymptomatic group (p = 0.03). Forty-one (82%) shoulders in the symptomatic group had grade III/IV ACJ arthritis compared to 31 (65%) in the asymptomatic group (p = 0.05). However, 44 out of 48 (92%) shoulders in the asymptomatic group had signs of osteoarthritis on MRI scans.

CONCLUSIONS

In contrast to recent reports, the present study shows that MRI is not helpful in making the diagnosis of ACJ arthritis. A focused history and clinical examination should remain the mainstay for surgical decision making.

LEVEL OF EVIDENCE

Level 3.

Predictive findings on magnetic resonance imaging in patients with symptomatic acromioclavicular osteoarthritis

BACKGROUND

A magnetic resonance imaging (MRI) scan of the shoulder can have added value in diagnosing symptomatic osteoarthritis of the acromioclavicular (AC) joint. Specific MRI signs have been recognized but not analyzed extensively before. This study aims to identify predictive MRI signs in patients with symptomatic AC osteoarthritis.

METHODS

The MRI scans of 70 patients with symptomatic AC osteoarthritis were compared with those of 70 patients with subacromial pain syndrome and no clinical signs of symptomatic AC osteoarthritis. Seven variables were evaluated on the MRI scans of the AC joint: joint space narrowing, inferior osteophytes, joint effusion, osteolysis, bone marrow edema, impression on the supraspinatus, and inferior joint distension. Logistic regression analysis of these variables was performed.

RESULTS

The presence of inferior osteophytes, bone marrow edema, impression on the supraspinatus, and inferior joint distension was individually associated with symptomatic AC osteoarthritis. Bone marrow edema was observed only in patients with symptomatic AC osteoarthritis. Multivariate analysis showed a significant association between inferior joint distension, as well as impression on the supraspinatus muscle, and symptomatic AC osteoarthritis. The area under the receiver operating characteristic curve in the multivariate logistic model was 0.839 (95% confidence interval, 0.771 to 0.907). Interobserver and intraobserver variability showed good to excellent κ values (range, 0.68 to 0.88).

CONCLUSION

We identified predictive MRI signs in patients with symptomatic AC osteoarthritis. These findings, including bone marrow edema, inferior joint distension, and impression on the supraspinatus muscle, showed good discriminative ability. They are practical and easy to use and can assist the physician in diagnosing symptomatic AC osteoarthritis.

The Diagnostic Reproducibility of Tomosynthesis for the Correlation between Acromiohumeral Distance and Rotator Cuff Size or Type

Objective

To correlate the acromiohumeral distance (AHD) using tomosynthesis and rotator cuff (RC) pathology and various anatomical indices and to assess the diagnostic reproducibility of tomosynthesis for the evaluation of subacromial impingement.

Materials and Methods

A retrospective review of 63 patients with clinically suspected subacromial impingement was conducted. Two musculoskeletal radiologists independently measured the following quantitative data: the AHD on plain radiographs and the AHD at three compartments (anterior, middle, and posterior) using tomosynthesis, computed tomography (CT) arthrography, or magnetic resonance (MR) arthrography. To investigate the association between the AHD and RC pathology and various anatomical indices, we reviewed the arthroscopic operation record as the referenced standard.

Results

The size of rotator cuff tear (RCT) in full-thickness tears displayed a significant inverse correlation with the middle and the posterior tomosynthetic AHDs (p < 0.05). The results of an ANOVA revealed that the middle tomosynthetic AHD retained a significant association with the type of RCT (p = 0.042), and the posterior tomosynthetic AHD retained significance for the size of RCT in a full-thickness tear (p = 0.024). The inter-modality correlation exhibited significant agreement especially among the plain radiography, tomosynthesis, and CT or MR arthrography (p < 0.05). The intraobserver and interobserver correlation coefficients (ICCs) displayed excellent agreement (ICC = 0.896–0.983). The humeral head diameter and glenoid height were significantly correlated with patient height and weight.

Conclusion

Acromiohumeral distance measurement using tomosynthesis is reproducible compared with other modalities.

A comprehensive rehabilitation program for posterior instability of the shoulder

Posterior shoulder instability is recognised as being less prevalent than anterior instability, however the diagnosis of this pathology is easily overlooked or missed and this may contribute to an underestimation of prevalence. Recently, there has been increasing recognition of this condition and consequently a greater requirement for knowledge of diagnostic procedures and treatment directions. Currently there is limited research into the conservative management of posterior instability, although it is recommended as first-line treatment prior to surgical review, particularly in those with an atraumatic instability mechanism. The aim of this paper is to outline a comprehensive rehabilitation program for the conservative management of posterior instability with a focus on scapular and humeral head control. The information provided includes extensive written information, flowcharts, figures and a table of management parameters that will provide therapists with adequate detail to replicate the program in the clinical setting.

Arthroscopically assisted reduction of acute acromioclavicular joint dislocation using a single double-button device: Medium-term clinical and radiological outcomes

INTRODUCTION

Double-button devices for endoscopic management of acute acromioclavicular joint dislocation (ACJD) provide satisfactory short-term functional and radiological results. However, little exists in the literature regarding the long- and medium-term results of these implants, especially regarding the evolution of the acromioclavicular joint (ACJ).

HYPOTHESIS

Satisfactory and steady long- and medium-term outcomes can be achieved in patients with acute ACJD undergoing endoscopically assisted ACJ repair using a single double-button device.

MATERIAL AND METHOD

A retrospective single-center study was conducted in patients with acute Rockwood III and IV ACJD treated endoscopically with a single double-button device from October 2008 to October 2010, allowing a minimum 5-year follow-up. Functional evaluation used Constant and Quick-DASH scores. Clinical evidence of dislocation recurrence was combined with bilateral Zanca views to assess coracoclavicular distance. Acromioclavicular osteoarthritis was evaluated on the Paxinos test and Zanca views.

RESULTS

Nineteen of the 25 operated patients were seen at a mean 76.9±8.5 months' follow-up. Mean age was 34.4±8.3 years. Mean Constant and Quick-DASH scores were 96.2±5.1 and 0.9±1.6 points, respectively. Four patients had a recurrence of their initial dislocation, 3 of whom had positive Paxinos test, whereas the 15 patients without recurrence had a negative test (p=0.004). Five patients had radiological evidence of ACJ osteoarthritis: all 4 patients with recurrence and 1 without (p=0.001).

CONCLUSION

Long- and medium-term radioclinical outcome of endoscopically assisted management of acute ACJD using a single double-button device seems to be satisfactory and steady over time. Recurrence of the initial dislocation appears to be related to onset of degenerative ACJ arthropathy.

LEVEL OF EVIDENCE

Therapeutic type IV-Retrospective case series.

A concise evidence-based physical examination for diagnosis of acromioclavicular joint pathology: a systematic review

OBJECTIVES

The clinical examination of the shoulder joint is an undervalued diagnostic tool for evaluating acromioclavicular (AC) joint pathology. Applying evidence-based clinical tests enables providers to make an accurate diagnosis and minimize costly imaging procedures and potential delays in care. The purpose of this study was to create a decision tree analysis enabling simple and accurate diagnosis of AC joint pathology.

METHODS

A systematic review of the Medline, Ovid and Cochrane Review databases was performed to identify level one and two diagnostic studies evaluating clinical tests for AC joint pathology. Individual test characteristics were combined in series and in parallel to improve sensitivities and specificities. A secondary analysis utilized subjective pre-test probabilities to create a clinical decision tree algorithm with post-test probabilities.

RESULTS

The optimal special test combination to screen and confirm AC joint pathology combined Paxinos sign and O'Brien's Test, with a specificity of 95.8% when performed in series; whereas, Paxinos sign and Hawkins-Kennedy Test demonstrated a sensitivity of 93.7% when performed in parallel. Paxinos sign and O'Brien's Test demonstrated the greatest positive likelihood ratio (2.71); whereas, Paxinos sign and Hawkins-Kennedy Test reported the lowest negative likelihood ratio (0.35).

CONCLUSION

No combination of special tests performed in series or in parallel creates more than a small impact on post-test probabilities to screen or confirm AC joint pathology. Paxinos sign and O'Brien's Test is the only special test combination that has a small and sometimes important impact when used both in series and in parallel. Physical examination testing is not beneficial for diagnosis of AC joint pathology when pretest probability is unequivocal. In these instances, it is of benefit to proceed with procedural tests to evaluate AC joint pathology. Ultrasound-guided corticosteroid injections are diagnostic and therapeutic. An ultrasound-guided AC joint corticosteroid injection may be an appropriate new standard for treatment and surgical decision-making.

LEVEL OF EVIDENCE

II - Systematic Review.

Managing acromio-clavicular joint pain: a scoping review

BACKGROUND

Shoulder pain secondary to acromioclavicular joint pain is a common presentation in primary and secondary care but is often poorly managed as a result of uncertainty about optimal treatment strategies. Osteoarthritis is the commonest cause. Although acromioclavicular pain can be treated non-operatively and operatively, there appears to be no consensus on the best practice pathway of care for these patients, with variations in treatment being common place. The present study comprises a scoping review of the current published evidence for the management of isolated acromioclavicular pain (excluding acromioclavicular joint dislocation).

METHODS

A comprehensive search strategy was utilized in multiple medical databases to identify level 1 and 2 randomised controlled trials, nonrandomised controlled trials and systematic reviews for appraisal.

RESULTS

Four systematic reviews and two randomised controlled trials were identified. No direct studies have compared the benefits or risks of conservative versus surgical management in a controlled environment.

CONCLUSIONS

High-level studies on treatment modalities for acromioclavicular joint pain are limited. As such, there remains little evidence to support one intervention or treatment over another, making it difficult to develop any evidenced-based patient pathways of care for this condition.Level of evidence: 2A.

Bone scintigraphy in patients with pain

Nuclear medicine imaging is widely used in pain medicine. Low back pain is commonly encountered by physicians, with its prevalence from 49% to 70%. Computed tomography (CT) or magnetic resonance imaging (MRI) are usually used to evaluate the cause of low back pain, however, these findings from these scans could also be observed in asymptomatic patients. Bone scintigraphy has an additional value in patients with low back pain. Complex regional pain syndrome (CRPS) is defined as a painful disorder of the extremities, which is characterized by sensory, autonomic, vasomotor, and trophic disturbances. To assist the diagnosis of CRPS, three-phase bone scintigraphy is thought to be superior compared to other modalities, and could be used to rule out CRPS due to its high specificity. Studies regarding the effect of bone scintigraphy in patients with extremity pain have not been widely conducted. Ultrasound, CT and MRI are widely used imaging modalities for evaluating extremity pain. However, SPECT/CT has an additional role in assessing pain in the extremities.

Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial

Background

Labral repair and biceps tenodesis are routine operations for superior labrum anterior posterior (SLAP) lesion of the shoulder, but evidence of their efficacy is lacking. We evaluated the effect of labral repair, biceps tenodesis and sham surgery on SLAP lesions.

Methods

A double-blind, sham-controlled trial was conducted with 118 surgical candidates (mean age 40 years), with patient history, clinical symptoms and MRI arthrography indicating an isolated type II SLAP lesion. Patients were randomly assigned to either labral repair (n=40), biceps tenodesis (n=39) or sham surgery (n=39) if arthroscopy revealed an isolated SLAP II lesion. Primary outcomes at 6 and 24 months were clinical Rowe score ranging from 0 to 100 (best possible) and Western Ontario Shoulder Instability Index (WOSI) ranging from 0 (best possible) to 2100. Secondary outcomes were Oxford Instability Shoulder Score, change in main symptoms, EuroQol (EQ-5D and EQ-VAS), patient satisfaction and complications.

Results

There were no significant between-group differences at any follow-up in any outcome. Between-group differences in Rowe scores at 2 years were: biceps tenodesis versus labral repair: 1.0 (95% CI −5.4 to 7.4), p=0.76; biceps tenodesis versus sham surgery: 1.6 (95% CI −5.0 to 8.1), p=0.64; and labral repair versus sham surgery: 0.6 (95% CI −5.9 to 7.0), p=0.86. Similar results—no differences between groups—were found for WOSI scores. Postoperative stiffness occurred in five patients after labral repair and in four patients after tenodesis.

Conclusion

Neither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied.

Trial registration number

ClinicalTrials.gov identifier: NCT00586742

Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance

BACKGROUND

Physical examination tests of the shoulder (PETS) are clinical examination maneuvers designed to aid the assessment of shoulder complaints. Despite more than 180 PETS described in the literature, evidence of their validity and usefulness in diagnosing the shoulder is questioned.

METHODS

This meta-analysis aims to use diagnostic odds ratio (DOR) to evaluate how much PETS shift overall probability and to rank the test performance of single PETS in order to aid the clinician's choice of which tests to use. This study adheres to the principles outlined in the Cochrane guidelines and the PRISMA statement. A fixed effect model was used to assess the overall diagnostic validity of PETS by pooling DOR for different PETS with similar biomechanical rationale when possible. Single PETS were assessed and ranked by DOR. Clinical performance was assessed by sensitivity, specificity, accuracy and likelihood ratio.

RESULTS

Six thousand nine-hundred abstracts and 202 full-text articles were assessed for eligibility; 20 articles were eligible and data from 11 articles could be included in the meta-analysis. All PETS for SLAP (superior labral anterior posterior) lesions pooled gave a DOR of 1.38 [1.13, 1.69]. The Supraspinatus test for any full thickness rotator cuff tear obtained the highest DOR of 9.24 (sensitivity was 0.74, specificity 0.77). Compression-Rotation test obtained the highest DOR (6.36) among single PETS for SLAP lesions (sensitivity 0.43, specificity 0.89) and Hawkins test obtained the highest DOR (2.86) for impingement syndrome (sensitivity 0.58, specificity 0.67). No single PETS showed superior clinical test performance.

CONCLUSIONS

The clinical performance of single PETS is limited. However, when the different PETS for SLAP lesions were pooled, we found a statistical significant change in post-test probability indicating an overall statistical validity. We suggest that clinicians choose their PETS among those with the highest pooled DOR and to assess validity to their own specific clinical settings, review the inclusion criteria of the included primary studies. We further propose that future studies on the validity of PETS use randomized research designs rather than the accuracy design relying less on well-established gold standard reference tests and efficient treatment options.

Association between acromioclavicular joint pain and capsular bulging in adolescent baseball players

PURPOSE

The purpose of this study was to investigate the association between acromioclavicular (AC) joint pain and superior capsular bulging assessed by ultrasound in adolescent baseball players.

METHODS

One hundred and fifty players (1st-8th graders) were examined. All subjects underwent physical examinations, including assessment of tenderness on the AC joint and provocative tests (the Buchberger's test and the cross-body adduction stress test). Bilateral AC joints with the arm in both the resting and the cross-body positions were examined by ultrasound.

RESULTS

Twelve of 150 players (8 %) had AC symptoms with both positive tenderness and positive provocative tests. Interestingly, their prevalence increased with age-one of the 70 (1.4 %) 1st-3rd graders, six of 46 (13 %) 4th-6th graders and five of 34 (15 %) 7th-8th graders. Ultrasonography of AC joints in the cross-body position showed that the difference in superior capsular bulging between the throwing and non-throwing sides was significantly greater in symptomatic players (1.6 ± 1.2 mm) than in asymptomatic players (0.2 ± 0.8 mm) (p = 0.002).

CONCLUSION

The prevalence of superior capsular bulging was significantly higher in adolescent baseball players with AC joint pain than in those without it. In adolescent baseball players with shoulder pain, AC joint symptoms should be considered amongst potential causes. Careful observation of these patients is suggested in cases of superior capsular bulging of the AC joint as determined by ultrasonography.

LEVEL OF EVIDENCE

III.

Common sports-related shoulder injuries

Shoulder pain is commonly treated in general practice; its causes are often multi-factorial. The focus of this article is on sports-related shoulder injuries likely to be seen in the community. This article aims to overview the presentation, assessment and management of these conditions in general practice.

Ultrasound of the coracoclavicular ligaments in the acute phase of an acromioclavicular disjonction: Comparison of radiographic, ultrasound and MRI findings

OBJECTIVES

Acromioclavicular joint injuries are typically diagnosed by clinical and radiographic assessment with the Rockwood classification, which is crucial for treatment planning. The purpose of this study was to describe how the ultrasound findings of acromioclavicular joint injury compare with radiography and MRI findings.

METHODS

Forty-seven patients with suspected unilateral acromioclavicular joint injury after acute trauma were enrolled in this prospective study. All patients underwent digital radiography, ultrasound and 3T MRI. A modified Rockwood classification was used to evaluate the coracoclavicular ligaments. The classifications of acromioclavicular joint injuries diagnosed with radiography, ultrasound and MRI were compared. MRI was used as the gold standard.

RESULTS

The agreement between the ultrasound and MRI findings was very good, with a correlation coefficient of 0.83 (95 % CI: 0.72-0.90; p < 0.0001). Ultrasound detected coracoclavicular ligament injuries with a sensitivity of 88.9 %, specificity of 90.0 %, positive predictive value of 92.3 % and negative predictive value of 85.7 %. The agreement between the ultrasound and radiography findings was poor, with a correlation coefficient of 0.69 (95 % CI: 0.51-0.82; p < 0.0001).

CONCLUSION

Ultrasound is an effective examination for the diagnostic work-up of lesions of the coracoclavicular ligaments in the acute phase of an acromioclavicular injury.

KEY POINTS

• Ultrasound is appropriate for acute acromioclavicular trauma due to its accessibility. • Ultrasound contributes to the diagnostic work-up of acute lesions of the coracoclavicular ligaments. • Ultrasound is appropriate in patients likely to benefit from surgical treatment. • Ultrasound could be a supplement to standard radiography in acute acromioclavicular trauma.

Diagnostic value of active protraction and retraction for sternoclavicular joint pain

Background

Sternoclavicular joint (SCJ) arthropathy is an uncommon cause of mechanical pain. The aim of this study is to evaluate the diagnostic value of two active clinical tests for localizing the sternoclavicular joint as the source of mechanical pain.

Methods

All patients between June 2011 and October 2013 that visited the orthopedic departments of three hospitals with atraumatic pain in the area of the SC joint were evaluated. Local swelling, pain at palpation, pain during arm elevation and two newly described tests (pain during active scapular protraction and retraction) were evaluated. CT images were evaluated. The patients were then divided into two groups according to whether they had a ≥50% decrease in pain following the SCJ injection. Sensitivity and specificity for local swelling, the four clinical tests and CT-scan were measured.

Results

Forty eight patients were included in this study and SC joint pain was confirmed in 44. The tests with highest sensitivity were pain on palpation, (93% sensitivity) and pain during active scapular protraction (86%). CT-scan showed a sensitivity of 84%. Local swelling showed a high specificity (100%).

Conclusion

Pain at the SCJ during active scapular protraction is a good clinical diagnostic tool for SC arthropathy.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-421) contains supplementary material, which is available to authorized users.

Is arthroscopic distal clavicle resection necessary for patients with radiological acromioclavicular joint arthritis and rotator cuff tears? A prospective randomized comparative study

BACKGROUND

The failure of subacromial decompression may be attributed to persistent symptoms of acromioclavicular joint (ACJ) arthritis, while inferior clavicular spurs of the ACJ may be associated with failed healing of repaired rotator cuffs.

PURPOSE

To evaluate the clinical effectiveness of arthroscopic distal clavicle resection (DCR) in patients with rotator cuff tears and concomitant asymptomatic radiological ACJ arthritis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 78 patients with rotator cuff tears in addition to radiological and asymptomatic ACJ arthritis who were scheduled for arthroscopic rotator cuff repair were prospectively randomized into 2 groups. Patients underwent arthroscopic rotator cuff repair with acromioplasty. Patients in group 1 (39 patients) underwent additional arthroscopic DCR, while patients in group 2 (39 patients) did not. Clinical outcomes of the 2 groups were compared using the visual analog scale (VAS) for pain, range of motion, Constant score, and American Shoulder and Elbow Surgeons (ASES) score up to at least 24 months. The structural integrity of repaired rotator cuffs was assessed using ultrasonography, computed tomography arthrography, or MRI at least 6 months after surgery. To evaluate ACJ instability, weighted stress radiography of the ACJ was studied at 6 and 12 months postoperatively.

RESULTS

Patients in both groups showed significant improvement in the VAS score and all functional scores at final follow-up (mean, 29.2 months; range, 24-46 months) without significant differences between the 2 groups (P > .05). Results (mean ± SD) for preoperative group 1/group 2 and postoperative group 1/group 2 were as follows, respectively: 7.2 ± 1.8/6.1 ± 1.9 (P = .02) and 0.6 ± 1.8/0.6 ± 0.9 (P = .97) for the VAS score, 74.1 ± 5.7/73.8 ± 8.0 (P = .87) and 96.3 ± 5.7/95.7 ± 4.6 (P = .77) for the Constant score, and 47.0 ± 10.3/50.8 ± 14.1 (P = .22) and 91.5 ± 15.5/94.5 ± 11.8 (P = .55) for the ASES score. Failed cuff healing occurred in 9 patients (23%) in group 1 and 10 patients (26%) in group 2, with no significant difference (P = .95). In group 1, there were 2 patients (5.0%) with ACJ subluxation on weighted stress radiography at 6 months postoperatively. These patients complained of gross protrusion and ACJ tenderness.

CONCLUSION

Preventive arthroscopic DCR in patients with rotator cuff tears and concomitant asymptomatic radiological ACJ arthritis did not result in better clinical or structural outcomes, and it did lead to symptomatic ACJ instability in some patients. Preventive arthroscopic DCR is not recommended in patients with radiological but asymptomatic ACJ arthritis. Further long-term follow-up is needed to confirm the development of symptoms in ACJ arthritis.

Successful injection of the acromioclavicular joint with use of ultrasound: anatomy, technique, and follow-up

BACKGROUND

Injection into the acromioclavicular (AC) joint is often inaccurate (approximately 50%) even in experienced hands. In light of new anatomic observations, we evaluate accuracy of an innovative ultrasound-guided method and follow the clinical course of successful therapeutic injections.

METHOD

Relevant anatomy was investigated in 200 three-dimensional computed tomography scans, 100 magnetic resonance images, and 14 cadavers. Baseline measurements of joint depth and width were performed ultrasonically in 100 normal volunteers; 50 symptomatic patients were injected. Uniquely in a clinical ultrasound study, injection success was documented by arthrography. Outcomes after concomitant steroid instillation were observed for 6 months by visual analog scale (VAS) scores and pain provocation test results.

RESULTS

Anatomic studies showed that the widest area for joint penetration was anterior superior. Injection success rate was 96%, overwhelmingly on the first needle pass. Shallow joint depth allowed access with a standard 3-cm needle. Joint width diminished with age but did not reduce injection success. Cadaveric joints admitted 1.2 ± 0.5 mL, but fluid ingress was initially blocked by soft tissues in one third of both cadaveric and clinical cases. Diligent follow-up after steroid injection showed sustained pain relief in the majority with isolated AC disease but significantly less in those with concomitant shoulder disorders.

CONCLUSION

This high level of clinical injection success, irrefutably substantiated with arthrography, has not been previously demonstrated. The anterior superior aspect of the joint is the preferred place for entry. Initial intra-articular blockage to fluid inflow is common but can be surmounted. Encouraging 6-month results of steroid instillation in isolated AC disease do not apply to patients with coexisting shoulder pathologic processes.

Shoulder diagnoses in secondary care, a one year cohort

BACKGROUND

Shoulder pain is common in the general population. Reports on specific diagnoses in general populations are scarce and only from primary care. The diagnostic distribution of shoulder disorders in secondary care is not reported. Most of the clinical research in the shoulder field is done in hospital settings. The aim of this study was to identify the diagnoses in a 1-year cohort in a hospital-based outpatient clinic using standardized diagnostic criteria and to compare the results with previous studies.

METHODS

A diagnostic routine was conducted among patients referred to our physical medicine outpatient clinic at Oslo University Hospital. Diagnostic criteria were derived from the literature and supplemented with research criteria.

RESULTS

Of 766 patients diagnosed, 55% were women and the mean age was 49 years (range 19-93, SD ± 14). The most common diagnoses were subacromial pain (36%), myalgia (17%) and adhesive capsulitis (11%). Subacromial pain and adhesive capsulitis were most frequent in persons aged 40-60 years. Shoulder myalgia was most frequent in age groups under 40. Labral tears and instability problems (8%) were most frequent in young patients and not present after age 50. Full-thickness rotator cuff tears (8%) and glenohumeral osteoarthritis (4%) were more prevalent after the age of 60. Few differences were observed between sexes. We identified three studies reporting shoulder diagnoses in primary care.

CONCLUSION

Subacromial pain syndrome, myalgia and adhesive capsulitis were the most prevalent diagnoses in our study. However, large differences in prevalence between different studies were found, most likely arising from different use of diagnostic criteria and a difference in populations between primary and secondary care. Of the diagnoses in our cohort, 20% were not reported by the studies from primary care (glenohumeral osteoarthritis, full thickness rotator cuff tears, labral tears and instabilities).

A novel radiographic index for the diagnosis of posterior acromioclavicular joint dislocations

BACKGROUND

Posterior acromioclavicular (AC) joint dislocations are frequently misclassified because posterior translation of the clavicle is difficult to evaluate in Zanca radiograph views. A novel radiographic index was used in this study to accurately diagnose posterior dislocations of the AC joint.

HYPOTHESIS

This novel index has a high degree of accuracy for the diagnosis of posterior AC joint dislocations.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

This was an analytic, descriptive study of 150 patients with different grades of AC injuries according to the Rockwood classification (30 patients for each grade of injury: I, II, III, IV, and V). The diagnosis of an AC injury was made both clinically and radiographically by using comparative Zanca and axillary views. Two measurements were performed in Zanca views: the coracoclavicular distance and the AC width distance. A width index was calculated for each patient. The Student t test, Bonferroni test, logistic regression, linear regression, and receiver operating characteristic (ROC) curves were used for statistical analysis. Forty cases were impartially selected to obtain a κ concordance value.

RESULTS

The average value of the AC width index per group (according to the Rockwood classification) was as follows: type I, 2.1% (range, -12% to 25%); type II, 4.2% (range, -19% to 29%); type III, 19.1% (range, -59% to 91%); type IV, 110.3% (range, 47% to 181%); and type V, -3.8% (range, -71% to 62%). There was a significant difference between the average width index in the patients with type IV injuries and those in the remaining groups (P < .05). The ROC curve showed that a width index of 60% has a sensitivity of 95.7% and specificity of 97.5%, with a positive predictive value of 96.7% and negative predictive value of 95.6% to predict a type IV injury. Intraobserver reliability was rated as substantial agreement for each of 3 observers; the interobserver reliability of the 3 independent raters was almost perfect.

CONCLUSION

An AC width index of ≥60% is highly accurate for the diagnosis of a posterior AC joint dislocation, with high intraobserver and interobserver concordance.

A new test for acromio-clavicolar pathology

BACKGROUND

A prospective study was established to assess the sensitivity and specificity of the new Saccomanni (SAC) test for isolated AC pathology, and compare with 4 commonly used clinical tests.

MATERIALS AND METHODS

The Saccomanni (Sac) test is essentially the cross-adduction test, with the addition of attempted elevation against resistance. In a positive test, this results in some pain and the inability of the patient to maintain the arm in the adducted and elevated position against resistance. Fifty-eight patients with isolated AC joint symptoms were assessed in random order with the Saccomanni test and 4 other tests. A corticosteroid and local anaesthetic injection was administered into the AC joint space. The Saccomanni test and 4 other tests were then repeated following the injection. After the injection, a symptom free clinical examination was used as a measure of true positive tests.

STUDY DESIGN

Case series.

RESULTS

The SAC test showed a sensitivity of 98% and specificity is 91.7%. All 4 other tests were less sensitive.

CONCLUSION

The SAC test is a highly sensitive test in patients presenting with isolated AC related symptoms. This study is an innovation for clinical tests in the world. The primary aim of this study was to assess the diagnostic sensitivity of my newly described SAC test. From the present study, it can be concluded that the easy-to use SAC is a highly sensitive test to evaluate AC joint pathology, when compared to other standard tests.

CLINICAL RELEVANCE

Level III, Diagnostic Study of Nonconsecutive Patients.

Overload and neovascularization of Achilles tendons in young artistic and rhythmic gymnasts compared with controls: an observational study

The incidence of Achilles tendinopathy is very high in young female gymnasts (17.5 %). According to literature, ecography screenings show the tendons thickening, but at the same time it does not reveal a direct link to the clinical picture. The neovessels are involved in the pathophysiological process of Achilles tendinopathy. For this reason, we wanted to verify there between perfusion tendon values and the type of sport activity. We performed a clinical observational study monitoring the oximetry of the Achilles tendon and the epidemiological data of 52 elite female (artistic and rhythmic) gymnasts versus 21 age-matched controls. Analyzing the main limb, we revealed statistically higher oximetry values in the artistic gymnasts group (69.5 %) compared to the rhythmic gymnasts group (67.1 %) (t = 2.13; p = 0.01) and the sedentary group (66.2 %) (t = 2.70; p = 0.004), but we did not find any differences between rhythmic gymnasts group and the sedentary group (t = 0.68; p = 0.24). The multiple logistic regression model highlighted that the oximetry value of the main limb is not influenced by age, knowledge of the main limb, years of general and gymnastic sports activity (p > 0.05). We discovered an increase of Achilles tendon perfusion in the main limb in the artistic gymnast group. We hypothesize that specific figures of artistic sports activity are responsible for muscle overload and gastrocnemius-soleus group and, at the same time, these figures cause hyperperfusion of the tendon. Prospective longitudinal studies could explain if this could become a predictive sign of the next Achilles tendinopathy onset.

Shoulder pain in primary care: diagnostic accuracy of clinical examination tests for non-traumatic acromioclavicular joint pain

BACKGROUND

Despite numerous methodological flaws in previous study designs and the lack of validation in primary care populations, clinical tests for identifying acromioclavicular joint (ACJ) pain are widely utilised without concern for such issues. The aim of this study was to estimate the diagnostic accuracy of traditional ACJ tests and to compare their accuracy with other clinical examination features for identifying a predominant ACJ pain source in a primary care cohort.

METHODS

Consecutive patients with shoulder pain were recruited prospectively from primary health care clinics. Following a standardised clinical examination and diagnostic injection into the subacromial bursa, all participants received a fluoroscopically guided diagnostic block of 1% lidocaine hydrochloride (XylocaineTM) into the ACJ. Diagnostic accuracy statistics including sensitivity, specificity, predictive values, positive and negative likelihood ratios (LR+ and LR-) were calculated for traditional ACJ tests (Active Compression/O'Brien's test, cross-body adduction, localised ACJ tenderness and Hawkins-Kennedy test), and for individual and combinations of clinical examination variables that were associated with a positive anaesthetic response (PAR) (P≤0.05) defined as 80% or more reduction in post-injection pain intensity during provocative clinical tests.

RESULTS

Twenty two of 153 participants (14%) reported an 80% PAR. None of the traditional ACJ tests were associated with an 80% PAR (P<0.05) and combinations of traditional tests were not able to discriminate between a PAR and a negative anaesthetic response (AUC 0.507; 95% CI: 0.366, 0.647; P>0.05). Five clinical examination variables (repetitive mechanism of pain onset, no referred pain below the elbow, thickened or swollen ACJ, no symptom provocation during passive glenohumeral abduction and external rotation) were associated with an 80% PAR (P<0.05) and demonstrated an ability to accurately discriminate between an PAR and NAR (AUC 0.791; 95% CI 0.702, 0.880; P<0.001). Less than two positive clinical features resulted in 96% sensitivity (95% CI 0.78, 0.99) and a LR- 0.09 (95% CI 0.02, 0.41) and four positive clinical features resulted in 95% specificity (95% CI 0.90, 0.98) and a LR+ of 4.98 (95% CI 1.69, 13.84).

CONCLUSIONS

In this cohort of primary care patients with predominantly subacute or chronic ACJ pain of non-traumatic onset, traditional ACJ tests were of limited diagnostic value. Combinations of other history and physical examination findings were able to more accurately identify injection-confirmed ACJ pain in this cohort.

Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement

BACKGROUND

Impingement is a common cause of shoulder pain. Impingement mechanisms may occur subacromially (under the coraco-acromial arch) or internally (within the shoulder joint), and a number of secondary pathologies may be associated. These include subacromial-subdeltoid bursitis (inflammation of the subacromial portion of the bursa, the subdeltoid portion, or both), tendinopathy or tears affecting the rotator cuff or the long head of biceps tendon, and glenoid labral damage. Accurate diagnosis based on physical tests would facilitate early optimisation of the clinical management approach. Most people with shoulder pain are diagnosed and managed in the primary care setting.

OBJECTIVES

To evaluate the diagnostic accuracy of physical tests for shoulder impingements (subacromial or internal) or local lesions of bursa, rotator cuff or labrum that may accompany impingement, in people whose symptoms and/or history suggest any of these disorders.

SEARCH METHODS

We searched electronic databases for primary studies in two stages. In the first stage, we searched MEDLINE, EMBASE, CINAHL, AMED and DARE (all from inception to November 2005). In the second stage, we searched MEDLINE, EMBASE and AMED (2005 to 15 February 2010). Searches were delimited to articles written in English.

SELECTION CRITERIA

We considered for inclusion diagnostic test accuracy studies that directly compared the accuracy of one or more physical index tests for shoulder impingement against a reference test in any clinical setting. We considered diagnostic test accuracy studies with cross-sectional or cohort designs (retrospective or prospective), case-control studies and randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two pairs of review authors independently performed study selection, assessed the study quality using QUADAS, and extracted data onto a purpose-designed form, noting patient characteristics (including care setting), study design, index tests and reference standard, and the diagnostic 2 x 2 table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for the index tests. Meta-analysis was not performed.

MAIN RESULTS

We included 33 studies involving 4002 shoulders in 3852 patients. Although 28 studies were prospective, study quality was still generally poor. Mainly reflecting the use of surgery as a reference test in most studies, all but two studies were judged as not meeting the criteria for having a representative spectrum of patients. However, even these two studies only partly recruited from primary care.The target conditions assessed in the 33 studies were grouped under five main categories: subacromial or internal impingement, rotator cuff tendinopathy or tears, long head of biceps tendinopathy or tears, glenoid labral lesions and multiple undifferentiated target conditions. The majority of studies used arthroscopic surgery as the reference standard. Eight studies utilised reference standards which were potentially applicable to primary care (local anaesthesia, one study; ultrasound, three studies) or the hospital outpatient setting (magnetic resonance imaging, four studies). One study used a variety of reference standards, some applicable to primary care or the hospital outpatient setting. In two of these studies the reference standard used was acceptable for identifying the target condition, but in six it was only partially so. The studies evaluated numerous standard, modified, or combination index tests and 14 novel index tests. There were 170 target condition/index test combinations, but only six instances of any index test being performed and interpreted similarly in two studies. Only two studies of a modified empty can test for full thickness tear of the rotator cuff, and two studies of a modified anterior slide test for type II superior labrum anterior to posterior (SLAP) lesions, were clinically homogenous. Due to the limited number of studies, meta-analyses were considered inappropriate. Sensitivity and specificity estimates from each study are presented on forest plots for the 170 target condition/index test combinations grouped according to target condition.

AUTHORS' CONCLUSIONS

There is insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care. The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.

Surgical treatment of lateral clavicle fractures associated with complete coracoclavicular ligament disruption: Clinico-radiological outcomes of acromioclavicular joint sparing and spanning implants

Purpose:

Distal clavicle fracture associated with complete coracoclavicular ligament disruption represents an unstable injury, and osteosynthesis is recommended. This study was performed (1) to retrospectively analyse the clinico-radiological outcomes of two internal fixation techniques, and (2) to identify and analyse radiographic fracture patterns of fracture that are associated with this injury.

Materials and Methods:

A total of 15 patients underwent osteosynthesis with either (1) acromioclavicular joint-spanning implants (Group 1, Hook plate device, n = 10) or (2) joint-sparing implants (Group 2, distal radius plate, n = 5); these were reviewed at a mean period of 26.1 months (12 to 40 months). Clinical outcomes were measured using Constant Score (CS), Simple Shoulder Test (SST), and Walch ACJ score (WS). Radiographs and ultrasonography were used to assess the glenohumeral and acromioclavicular joints, and the subacromial space. Preoperative radiographs were analyzed for assessment of fracture lines to identify radiographic patterns. Statistical analysis of the data was performed to determine any significant differences between the two groups.

Results:

The overall clinical outcome was satisfactory (CS 80.8, SST 11.3, WS 17.6) and a high union rate (93.3%) was observed. Radiographic complications (acromioclavicular degeneration and subluxation, hook migration, abnormal ossification) did not negatively influence the final clinical outcomes. Four distinct radiographic fracture patterns were observed. A statistically significant difference ( P < 0.05) was observed in the reoperation rates between the two groups.

Conclusions:

Internal fixation of this fracture pattern is associated with a high union rate and favorable clinical outcomes with both techniques. A combination of distal radius plate and ligament reconstruction device resulted in stable fixation and significantly lower reoperation rates, and should be used when fracture geometry permits (Types 1 and 2).

Design:

Retrospective review of a consecutive clinical case series.

Setting:

Level 1 academic trauma service, Public Hospital.

Accuracy of acromioclavicular joint injections

BACKGROUND

Injection to the acromioclavicular (AC) joint can be both diagnostic and therapeutic.

PURPOSE

The purpose of this study was to evaluate the accuracy of in vivo AC joint injections.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty patients with pain localized to the AC joint were injected with 1 mL of 1% lidocaine and 0.5 mL of radiographic contrast material (Isovue). Radiographs of the AC joint were taken after the injection. Each radiograph was reviewed by a musculoskeletal radiologist and graded as intra-articular, extra-articular, or partially intra-articular.

RESULTS

Of the 30 injections performed, 13 (43.3%) were intra-articular, 7 (23.3%) were partially articular, and 10 (33.3%) were extra-articular. When the intra-articular and the partially articular groups were combined, 20 patients (66.7%) had some contrast dye in the AC joint.

CONCLUSION

This study demonstrates that despite the relatively superficial location of the AC joint, the clinical accuracy of AC joint injections remains relatively low.

Acromioclavicular joint separations grades I-III: a review of the literature and development of best practice guidelines

Acromioclavicular joint (ACJ) separation injuries are common injuries among sporting populations. ACJ separations are graded according to severity from grade I being a mild sprain to grade VI, which is severe dislocation with displacement. There is consensus in the literature that grade I-III ACJ separations are managed conservatively and grades IV-VI are managed surgically. Despite conservative care being recommended for lesser grades of injury, there is very little evidence in the literature as to what constitutes conservative care. Therefore, the purpose of this paper was, first, to review the relevant anatomy and kinematics of the ACJ and, second, to review the literature relating to current evidence of conservative management of ACJ injury. Using this data, a best practice guideline for conservative rehabilitation in grade I-III ACJ separations was developed. For the conservative management, a literature search was undertaken using the following databases in the Auckland University of Technology's electronic library resources; MEDLINE, CINAHL, SPORTDiscus™ and the Cochrane Library. The following keywords or phrases were used: 'acromioclavicular joint separations', 'injury', 'dislocations', 'rehabilitation', 'conservative care', 'physiotherapy' and 'exercise'. A total of 24 articles was identified. There were no randomized controlled trials (RCTs) that investigated conservative treatment for grade I-III ACJ sprains. Therefore, a narrative review was formulated covering the anatomy and biomechanics of the ACJ, injury mechanisms and relevant literature reviewed covering rehabilitation principles. Conservative management of grade I-III ACJ separations is still the main recommendation following this review. A best practice guideline for managing grade I-III ACJ separations is presented to help guide clinicians until well constructed RCTs are carried out to improve the conservative management of ACJ injuries.

Overload and neovascularization of shoulder tendons in volleyball players

BACKGROUND

In overhead sports like volleyball, the onset of a rotator cuff tendinopathy due to functional overload is a common observation. An angiofibroblastic etiopathogenesis has been hypothesized, whereby a greater anaerobic metabolism occurs in critical zones of the tendon with a lower degree of vascularization; this would induce collagen and extracellular matrix degradation, that could then trigger a compensatory neovascularization response. We performed a clinical observational study of 80 elite volleyball players, monitoring the perfusion values of the supraspinatus tendons by oximetry.

RESULTS

No statistically significant differences were found between the oximetry data and age, sex or years of sports activity, nor when comparing the right and left arm or the dominant and non-dominant arm. A statistically significant difference was found for the dominant arm values in relation to the competitive role, higher values being obtained in outside hitters (62.7%) than middle hitters (53.7%) (p = 0.01), opposite hitters (55.5%) (p = 0.02) and libero players (54.4%) (p = 0.008), whereas there were no differences in setters (56.2%) (p > 0.05).

CONCLUSIONS

The different tendon vascularization values found in players with different roles in the team may be attributed to a response to the specific biomechanical demands posed by the different overhead throwing roles.