Anterior-superior internal impingement of the shoulder: an evidence-based review

Preoperative Magnetic Resonance Imaging Accurately Detects the Arthroscopic Comma Sign in Subscapularis Tears

PURPOSE

To assess the accuracy and reliability of routine preoperative magnetic resonance imaging (MRI) in the detection of the comma sign compared with the gold standard of arthroscopic findings.

METHODS AND MATERIALS

Preoperative MRI exams in consecutive patients undergoing arthroscopic subscapularis tendon repair, over a 5-year time frame, were retrospectively reviewed for full-thickness tears of the subscapularis and supraspinatus tendons, fatty atrophy of the subscapularis and supraspinatus muscles, and status of the long head of the biceps tendon. Each case was also evaluated for presence or absence of a comma sign on MRI. Surgical findings served as the diagnostic standard of reference in determination of a comma sign.

RESULTS

The study cohort included 45 male and 10 female patients (mean age, 56; range, 32-80 years). A comma sign was present at arthroscopy in 19 patients (34.5%). Interclass and intrarater correlation showed 100% agreement in preoperative assessment of a comma sign on MRI. MRI showed an overall accuracy of 83.6% in diagnosis of a comma sign (sensitivity, 63.2%; specificity, 94.4%; positive predictive value, 85.7%; negative predictive value, 82.9%; positive likelihood ratio, 11.37; negative likelihood ratio, 0.39). No statistically significant association was observed between an arthroscopic comma sign and patient demographics or MRI findings of full-thickness rotator cuff tears, muscle fatty atrophy, or long head of the biceps tendon pathology.

CONCLUSIONS

MR imaging illustrates excellent reliability and good specificity and accuracy in detection of the arthroscopic comma sign in the setting of subscapularis tendon tearing. Detection of a comma sign on MRI may be important preoperative planning information in the arthroscopic management of patients with subscapularis tendon tears.

LEVEL OF EVIDENCE

Level IV, retrospective diagnostic study.

Arthroscopic rotator cuff repair with and without subacromial decompression is safe and effective: a clinical study

BACKGROUND

Subacromial decompression, that consists of the release of the coracoid-acromial ligament, subacromial bursectomy and anterior-inferior acromioplasty, has traditionally been performed in the management of this pathology. However, the purpose of subacromial decompression procedure is not clearly explained. Our reaserch aimed to analyse the differences among the outcomes of arthroscopic rotator cuff repair (RCR) made with suture anchors, with or without the subacromial decompression procedure.

METHODS

116 shoulders of 107 patients affected by rotator cuff (RC) tear were treated with Arthroscopic RCR. In 54 subjectes, the arthroscopic RCR and the subacromial decompression procedure (group A) were executed, whereas 53 took only arthroscopic RCR (group B). Clinical outcomes were evaluated through the use of the modified UCLA shoulder rating system, Wolfgang criteria shoulder score and Oxford shoulder score (OSS). Functional outcomes were assessed utilizing active and passive range of motion (ROM) of the shoulder, and muscle strength. The duration of the follow up and the configuration of the acromion were used to realize the comparison between the two groups.

RESULTS

In patients with 2 to 5 year follow up, UCLA score resulted greater in group A patients. In subjectes with longer than five years of follow up, group B patients showed considerably greater UCLA score and OSS if related with group A patients. In subjectes that had the type II acromion, group B patients presented a significant greater strength in external rotation.

CONCLUSION

The long term clinical outcomes resulted significantly higher in patients treated only with RCR respect the ones in patients underwent to RCR with subacromial decompression.

Kinematic patterns in normal and degenerative shoulders. Part II: Review of 3-D scapular kinematic patterns in patients with shoulder pain, and clinical implications

BACKGROUND

The global range of motion of the arm is the result of a coordinated motion of the shoulder complex including glenohumeral (GH), scapulothoracic, sternoclavicular and acromioclavicular joints.

METHODS

This study is a non-systematic review of kinematic patterns in degenerated shoulders. It is a based on our own research on the kinematics of the shoulder complex and clinical experience.

RESULTS

For patients with subacromial impingement syndrome without rotator-cuff tears, most kinematic studies showed a small superior humeral translation relative to the glenoid and decreased scapular lateral rotation and posterior tilt. These scapular kinematic modifications could decrease the subacromial space and favor rotator-cuff tendon injury. For patients with shoulder pain and restricted mobility, the studies showed a significant increase in scapular lateral rotation generally seen as a compensation mechanism of GH decreased range of motion. For patients with multidirectional GH instability, the studies found an antero-inferior decentering of the humeral head, decreased scapular lateral rotation and increased scapular internal rotation.

CONCLUSION

The clinical or instrumented assessment of the shoulder complex with a degenerative pathology must include the analysis of scapula-clavicle and trunk movements complementing the GH assessment. Depending on the individual clinical case, scapular dyskinesis could be the cause or the consequence of the shoulder degenerative pathology. For most degenerative shoulder pathologies, the rehabilitation program should take into account the whole shoulder complex and include first a scapular and trunk postural-correcting strategy, then scapulothoracic muscle rehabilitation (especially serratus anterior and trapezius inferior and medium parts) and finally neuromotor techniques to recover appropriate upper-limb kinematic schemas for daily and/or sports activities.

Beyond the Cuff: MR Imaging of Labroligamentous Injuries in the Athletic Shoulder

Shoulder disease is common in the athletic population and may arise as a consequence of a single traumatic episode or multiple repeated events. Associated labroligamentous injuries can result in substantial disability. Specific athletic and occupational activities result in predictable injury patterns. Imaging in general and magnetic resonance (MR) imaging, in particular, are vital in establishing the correct diagnosis and excluding common mimicking conditions, to ensure timely and appropriate management. In this review, the utility of MR imaging and MR arthrography will be explored in evaluation of shoulder disease, taking into account normal variants of the labroligamentous complex. Subsequently, broad categories of labral lesions and instability, external and internal impingement, as well as nerve entrapment syndromes, will be discussed, while emphasizing their imaging findings in the clinical context and illustrating key features. More recent concepts of internal impingement and secondary subacromial impingement will also be clarified.

Traumatic Supraspinatus Tears in Patients Younger Than 25 Years

Traumatic rotator cuff tears in patients younger than 25 years are rare events, with few reports in the literature. When compared with the more mature shoulder, the young, healthy supraspinatus tendon is a robust tendon that is able to absorb a significant amount of energy before tendon failure. Therefore, the diagnosis of a rotator cuff tear can be often overlooked in this population due to the patient's age. This is a report of traumatic supraspinatus repairs in patients younger than 25 years. Nine patients younger than 25 years were identified with a posttraumatic supraspinatus tear as visualized during routine diagnostic shoulder arthroscopy. These 9 patients represented 0.33% of all rotator cuff repairs during a 9-year period. Average patient age was 19.1 years (±3.7 years; range, 13 to 25 years). Magnetic resonance imaging failed to diagnose a rotator cuff tear in 50% of the patients. Mean delay from injury to surgery was 6.6 months. All tears were arthroscopically repaired. Concomitant anterior instability pathology was demonstrated among 66.7% of the patients. No complications were reported. At latest follow-up, all patients reported minimal to no shoulder pain and were tolerating strenuous work, activities, and sports without significant complaints. Even with advanced imaging, the diagnosis of a rotator cuff tear can often be missed in this patient population. Although clinical outcomes can be good, care must be taken to broaden the diagnostic differential in young patients with posttraumatic shoulder pain.

Intervenção da fisioterapia na síndrome de colisão do ombro

INTRODUÇÃO: Os problemas do ombro são responsáveis por cerca de 10% de todos os encaminhamentos para os fisioterapeutas, sendo a síndrome de colisão do ombro o diagnóstico mais comum entre as patologias do ombro, representando 44 a 65%. Contudo, a efectividade da fisioterapia nesta patologia continua a ser um tema em discussão. OBJECTIVO: Determinar a efectividade da fisioterapia no tratamento de pacientes com síndrome de colisão do ombro. METODOLOGIA: Pesquisa computadorizada nas bases de dados PubMed/Medline, B-on, SciELO e PEDro para identificar estudos randomizados controlados que avaliam várias intervenções de fisioterapia na síndrome de colisão do ombro. RESULTADOS: Nesta revisão foram incluídos dez estudos envolvendo 823 pacientes, com classificação metodológica de média aritmética 7.1 na escala de PEDro. Dos estudos incluídos nesta revisão, nove avaliaram a fisioterapia com a aplicação de técnicas manuais e exercícios terapêuticos, enquanto que três têm em conta a aplicação de agentes físicos. CONCLUSÕES: A evidência consultada nesta revisão sistemática sugere que a fisioterapia desempenha um papel fundamental no tratamento da síndrome de colisão do ombro, nomeadamente através da utilização de terapia manual e dos exercícios terapêuticos. O uso dos agentes físicos também apresenta algumas melhorias. Da pesquisa efectuada, sugere-se a relevância de novas investigações sobre o tratamento de fisioterapia com efeitos a longo prazo.

The acromial index is not predictive for failed rotator cuff repair

BACKGROUND

The main objective of this study was to evaluate the association between the acromial index (AI) and the incidence of recurrent tears of the rotator cuff (RC) in a cohort of patients with full thickness tears who underwent arthroscopic primary repair.

METHODS

A prognostic study of a prospective case series of 103 patients with full thickness RC tears was undertaken. The average age was 59.5 years (39-74) and follow-up was 30.81 months (12-72). True anterior-posterior X-rays were obtained during the pre-operative evaluation. Pre and post-operative magnetic resonance imaging (MRI) were recorded.

RESULTS

Eighteen cases with recurrent tears (17.4%) were seen on post-operative MRI. The average AI for patients with recurrent tears was 0.711 ± 0.065 and for patients without recurrent tears 0.710 ± 0.064 (p < 0.05). A positive association between age and recurrent tears of the RC was noted (average ages: recurrent tears group 63 ± 5.9 years; group without recurrent tears 58.8 ± 7.5 years) (r = -0.216; p = 0.029). We did not find an association between size of the primary tear and recurrent tears (r = -0.075; p < 0.05) or between degrees of retraction of the primary and recurrent tears of the cuff (r = -0.073; p < 0.05). We observed that 38.9% of the recurrent tears cases presented with more than one tendon affected before the arthroscopy. At follow-up, none of these recurrent tears showed more than one tendon affected on MRI evaluation.

CONCLUSION

In this study, we found that the AI radiological measurement is not a predictor for recurrent tears of the RC after primary arthroscopic repair.

Biomechanical comparison of intramedullary cortical button fixation and interference screw technique for subpectoral biceps tenodesis

PURPOSE

The purpose of this study was to biomechanically evaluate a new technique of intramedullary cortical button fixation for subpectoral biceps tenodesis and to compare it with the interference screw technique.

METHODS

We compared intramedullary unicortical button fixation (BicepsButton; Arthrex, Naples, FL) with interference screw fixation (Bio-Tenodesis screw; Arthrex) for subpectoral biceps tenodesis using 10 pairs of human cadaveric shoulders and ovine superficial digital flexor tendons. After computed tomography analysis, the specimens were mounted in a testing machine. Cyclic loading was performed (preload, 5 N; 5 to 70 N at 1.5 Hz for 500 cycles), recording the displacement of the tendon. Load to failure and stiffness were subsequently evaluated with a load-to-failure test (1 mm/s).

RESULTS

Cyclic loading showed a displacement of 11.3 ± 2.8 mm for intramedullary cortical button fixation and 9 ± 1.7 mm for interference screw fixation (P = .112). All specimens within the cortical button group passed the cyclic loading test, whereas 3 of 10 specimens within the interference screw group failed by tendon slippage at the screw-tendon-bone interface after a mean of 252 cycles (P = .221). Load-to-failure testing showed a mean load to failure of 218.8 ± 40 N and stiffness of 27.2 ± 7.2 N/mm for the intramedullary cortical button technique. For the interference screw, the mean load to failure was 212.1 ± 28.3 N (P = .625) and stiffness was 40.4 ± 13 N/mm (P = .056).

CONCLUSIONS

We could not find any major differences in load to failure when comparing the tested techniques for subpectoral biceps tenodesis. Intramedullary cortical button fixation showed no failure during cyclic testing. However, we found a 30% failure rate (3 of 10) for the interference screw fixation.

CLINICAL RELEVANCE

Intramedullary cortical button fixation provides an alternative technique for subpectoral biceps tenodesis with comparable and, during cyclic loading, even superior biomechanical properties to interference screw fixation.

Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the 'Scapular Summit'

The second international consensus conference on the scapula was held in Lexington Kentucky. The purpose of the conference was to update, present and discuss the accumulated knowledge regarding scapular involvement in various shoulder injuries and highlight the clinical implications for the evaluation and treatment of shoulder injuries. The areas covered included the scapula and shoulder injury, the scapula and sports participation, clinical evaluation and interventions and known outcomes. Major conclusions were (1) scapular dyskinesis is present in a high percentage of most shoulder injuries; (2) the exact role of the dyskinesis in creating or exacerbating shoulder dysfunction is not clearly defined; (3) shoulder impingement symptoms are particularly affected by scapular dyskinesis; (4) scapular dyskinesis is most aptly viewed as a potential impairment to shoulder function; (5) treatment strategies for shoulder injury can be more effectively implemented by evaluation of the dyskinesis; (6) a reliable observational clinical evaluation method for dyskinesis is available and (7) rehabilitation programmes to restore scapular position and motion can be effective within a more comprehensive shoulder rehabilitation programme.

Imaging evaluation of the rotator cuff

The rotator cuff is a complex network of interwoven tendons that plays a key role in glenohumeral movement and stability. Cuff abnormality is a common source of shoulder pain, but the clinical presentation is often nonspecific and, as a result, diagnostic imaging, especially magnetic resonance imaging, plays a key role in evaluating these patients. This article reviews imaging modalities available for evaluating the cuff, normal cuff anatomy, and common pathologic conditions that affect it.

Incomplete joint side tear of the subscapularis tendon with a small fragment in an adolescent tennis player: a case report

Case

In this case report, we presented the case of an adolescent tennis player with avulsion injury of the subscapularis tendon of the right shoulder.

Patients

A 17-year-old right-hand-dominant male tennis player visited our hospital complaining of pain in the anterior aspect of the right shoulder. We performed X-ray and three-dimensional computed tomography (3D-CT) and magnetic resonance imaging (MRI) scans for the diagnosis.

Results

Plain radiographs did not reveal the presence of lesion; however, 3D-CT and MRI scans showed a small bony fragment located between the humeral head and the glenoid of the scapula and a high-intensity area of the subscapularis tendon. He was subsequently diagnosed with incomplete joint side tear of the subscapularis tendon with a small bony fragment. Subsequently, we performed arthroscopic excision of the bony fragment and repair of the subscapularis tendon.

Conclusions

This case highlighted the presence of an injury with minor trauma associated with repeated tennis strokes in a skeletally immature patient.

Lesions of the biceps pulley as cause of anterosuperior impingement of the shoulder in the athlete: potentials and limits of MR arthrography compared with arthroscopy

PURPOSE

This study aimed to evaluate the diagnostic possibilities of MR arthrography in the correct identification of complex tears of the biceps pulley and their possible correlation with anterosuperior impingement (ASI) development.

MATERIALS AND METHODS

MR arthrography examinations of 23 athletes with clinical suspicion of ASI were reviewed. All examinations were obtained with a 1.5-T unit (Signa Horizon, GE Healthcare). The shoulders were studied with a dedicated surface coil with the patient's arm in the neutral position and in internal and external rotation. In five patients, images in abduction-external rotation (ABER) were obtained. Within 2 month after MR arthrography, the athletes underwent arthroscopic surgery.

RESULTS

MR arthrography images showed a spectrum of tears that, according to the Habermeyer classification, were subdivided into four groups: type 1 in three patients; type 2 in five; type 3 in seven; type 4 in eight. At arthroscopic evaluation, one patient presented type 1 lesion, five type 2, five type 3 and ten type 4. During arthroscopic dynamic manoeuvres, ASI signs were observed in three patients with type 3 lesion and in ten with type 4 lesion.

CONCLUSIONS

MR arthrography is the imaging modality of choice for evaluating lesions of the rotator interval structures, and only complex lesions of the biceps pulley are related to the development of ASI.