Defining functional shoulder range of motion for activities of daily living

Investigation of axioscapular muscle thickness in individuals with neck pain with and without scapular dysfunction

BACKGROUND

Scapular downward rotation (SDR) is associated with altered axioscapular muscles, including upper trapezius (UT), lower trapezius (LT), serratus anterior (SA), and levator scapulae (LS). SDR is commonly seen in patients with chronic non-specific neck pain (NP). However, the extent of muscle thickness changes in this population remains unclear.

OBJECTIVES

To investigate thickness of the axioscapular muscles between individuals with NP with SDR compared to those with NP and controls without scapular dysfunction (SD) DESIGN: A cross-sectional study.

METHOD

Sixty-six female participants were included, with 22 in each of the following groups: NP with SDR, NP without SD, and control without SD. Muscle thickness was taken using ultrasound imaging on the side of neck pain or dominant side, both at rest and during 120° arm flexion with a 1-kg weight. Ratios of the axioscapular muscle thickness were calculated for each condition.

RESULTS

The NP with SDR group showed significantly reduced LT thickness, both at rest and during arm elevation compared to the NP without SD and control without SD groups (p < 0.05). The NP without SD group demonstrated greater UT thickness at rest compared to the NP with SDR and control without SD groups (p ≤ 0.01). There were no differences in SA and LS thickness or in muscle ratios between the groups (p > 0.05).

CONCLUSIONS

Individuals with NP and SDR exhibited decreased LT thickness and those NP without SD showed greater UT thickness. This may suggest that scapular dysfunction (i.e., SDR) contributes to alterations in axioscapular muscle thickness in patients with NP.

Reverse shoulder arthroplasty implant design and configuration has a significant effect on conjoint tendon impingement

BACKGROUND

Anterior shoulder pain after reverse shoulder arthroplasty (RSA) is not uncommon and may be due to humeral impingement against the conjoint tendon during internal rotation (IR). It is unknown what effect different implant designs and configurations have on conjoint tendon impingement. The purpose of this study was to investigate the influence of several RSA implant design parameters on conjoint tendon impingement during IR.

METHODS

Twelve upper extremity cadavers were dissected to visualize and digitize the path of the coracobrachialis using a tracking system. This data were transformed onto the corresponding computer tomography derived bone models, while previous literature was used to approximate the muscle attachment locations for the conjoint tendon origin and short head of the biceps insertion. Each model then underwent three-dimensional virtual RSA implantation using a generic implant design. A baseline configuration was first implanted which utilized a 25 mm glenoid baseplate placed in 0° inclination and version and positioned flush to the inferior glenoid rim with a 36 mm glenosphere. The humeral baseline configuration consisted of an implant placed in 20° retroversion at a neck shaft angle (NSA) of 135°, centered on the humeral cut plane with a zero-thickness polyethylene cup. Additional implant designs were then configured by independently changing various design parameters including glenoid lateralization, glenosphere diameter, glenoid baseplate position, humeral polyethylene thickness, humeral component position, humeral NSA, and humeral version. Each implant configuration was then examined using a custom motion software which modeled the muscle path of both the coracobrachialis and short head of the biceps. IR was performed until conjoint tendon impingement was detected. All implant configurations were compared using a repeated measures analysis of variance (P < .05).

RESULTS

Glenosphere size, glenoid baseplate anterior-posterior and superior-inferior position, humeral polyethylene insert thickness, humeral anterior-posterior and medial-lateral position, and humeral version significantly influenced conjoint tendon impingement (P < .001). Glenoid lateralization and humeral NSA did not have a significant effect on conjoint tendon impingement (P > .293). Overall, earlier conjoint tendon impingement occurred with larger glenosphere sizes, anteriorly and superiorly positioned glenoid baseplates, greater polyethylene thickness, medially and posteriorly positioned humeral implants, and greater humeral retroversion.

CONCLUSION

RSA implant parameters and positions have been identified that can significantly increase the risk of conjoint tendon impingement, such as larger glenospheres, anterosuperior baseplate and glenosphere positioning, humeral implants or trays positioned medial and posterior, and increased humeral component retroversion. These results may be considered by surgeons preoperatively to limit conjoint tendon impingement, or intra-operatively when conjoint tendon impingement is identified.

Fluoroscopy-guided suprascapular and subscapular articular nerve blocks for chronic shoulder pain: A 12-week observational study

Introduction

Chronic shoulder pain is a common musculoskeletal complaint. This study evaluates the effectiveness of fluoroscopy-guided suprascapular (SSN) and subscapular (SCN) articular branch blocks in managing chronic shoulder pain. The primary objective was to assess pain relief using a numerical rating scale (NRS) and functional improvement using Shoulder Pain and Disability Index (SPADI) over 12 weeks.

Methods

This prospective, single-arm observational study included 70 adults with chronic shoulder pain (≥3 months) meeting predefined criteria. All patients underwent fluoroscopy-guided SSN and SCN articular branch blocks with bupivacaine (2 ml, 0.5 %) and triamcinolone (0.5 ml, 20 mg) per site. NRS and SPADI were recorded at baseline and biweekly for 12 weeks. Secondary outcomes included range of motion (ROM) improvements and night pain resolution. Statistical analysis involved repeated measures ANOVA for normally distributed data and non-parametric tests for skewed data (p < 0.05 considered significant).

Results

At 12 weeks, 78 % of patients achieved ≥50 % pain reduction. Mean NRS decreased from 7.6 ± 1.1 to 3.9 ± 1.1, while SPADI pain and disability scores improved by 57.1 % and 57.4 %, respectively (p < 0.001). Night pain resolved in all affected patients within two weeks. Repeated measures ANOVA confirmed significant improvements in pain and disability scores (p < 0.001). Mean lateral abduction improved by 29° (95 % CI: 22.8°-35.2°, p < 0.001).

Conclusion

Fluoroscopy-guided SSN and SCN articular branch blocks provide significant pain relief and functional improvement in chronic shoulder pain, offering a potential alternative to intra-articular injections or surgery in select patients.

Clinical Outcomes of Arthroscopic Treatment of High-grade Partial Thickness Rotator Cuff Tears with Augmentation using Bioinductive Collagen Implants Are Comparable to Tear Completion and Repair

PURPOSE

To evaluate and compare the functional outcomes and reoperation rates following bio-inductive collagen implant repair (BCIR) vs arthroscopic tear completion and rotator cuff repair (ARCR) for the management of partial rotator cuff tears at a minimum of 1 years follow-up.

METHODS

A retrospective review was carried out to identify patients ≥30 years old who underwent BCIR or ARCR for grade 3 partial thickness supraspinatus tears with ≥12 months follow up. Clinical outcomes assessed included range of motion, visual analogue score (VAS), American Shoulder Elbow Score (ASES) & Single Answer Numerical Evaluation (SANE) scores as well as clinical failure requiring revision surgery. A p-value of < 0.05 was considered to be statistically significant. The minimally important clinical difference (MCID) was calculated.

RESULTS

Participants included 48 patients who underwent BCIR and 37 who underwent ARCR, with a mean follow-up 27.3 ± 11.8 months, there were no significant baseline differences in demographics or tear characteristics between the cohorts. The mean surgical duration was shorter in the BCIR cohort (53 ± 10 vs 65 ± 17 minutes, p = 0.001). At final follow up there was no difference in ASES (p= .143), SANE (p = .167), VAS scores (p = .130), range of flexion (p = .159), abduction (p = .379) or external rotation (p = .281). Both groups obtained significant postoperative improvements (p < .02, for all). There was no difference in the achievement of the MCID for VAS (p = .999), SANE (p = .435) or ASES score (0.377). There was no significant difference in the rate of revision repair at final follow up 2.1% vs 5.4% (p = .577).

CONCLUSION

BCIR of high grade partial thickness rotator cuff tears results in reliable improvements in pain, shoulder function and range of motion equivalent to traditional suture anchor repair. There was no difference in the rate of MCID achievement or revision surgery.

STUDY DESIGN

Level III, retrospective comparative series.

Open repair of subscapularis tendon tears leads to complete relief of symptoms in the majority of patients, but often fails to restore functional range of motion

Purpose

To investigate the outcome of open subscapularis (SSC) repair in terms of complete relief of symptoms, regaining functional range of motion ((ROM), i.e. minimum ROM to complete all tasks of daily living) and retear rate.

Methods

Sixty-one patients who underwent open SSC repair between 2012 and 2019 were included in a retrospective cohort study. Primary outcome measures (complete relief of symptoms, obtaining functional ROM, SSC retears), were assessed at minimum 1-year follow-up. Prognostic factors for these outcome measures were identified.

Results

At final follow-up, 44 patients (72%) reported complete relief of symptoms. Pre-operatively, 23 patients (40%) had a functional ROM, which increased to 33 patients (54%) post-operatively. Eight Patients (13%) had a retear after a median follow-up of 21 months (range: 3-35). Lafosse type IV tears were associated with having persisting symptoms (OR 5, 95 confidence interval (CI) 1.2-17.9, p = 0.024) and retears (OR 7, 95 CI 1.9-37.7, p = 0.031).

Conclusion

The majority of patients reported complete relief of symptoms after SSC repair; however, only 54% obtained a functional ROM. Measuring outcome in terms of complete relief symptoms and regaining functional ROM is useful for the surgeon to evaluate the effect of surgical intervention and provides tangible information for patients.

Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation: A Clinical Practice Guideline

This evidence-based clinical practice guideline (CPG) aims to guide clinicians with recommendations covering the assessment, treatment, and prognosis of adults with shoulder pain with suspected rotator cuff (RC) tendinopathy, the nonsurgical medical care and rehabilitation of adults with RC tendinopathy, as well as the return to function and sport for elite and recreational athletes. This CPG includes recommendations for managing RC tendinopathy with or without calcifications and partial-thickness RC tears. J Orthop Sports Phys Ther 2025;55(4):235-274. Epub 30 January 2025. doi:10.2519/jospt.2025.13182.

A randomized controlled trial: Mobile app vs videoconference telerehabilitation for rotator cuff tendinopathy

IntroductionThe aim of this study was to compare the effectiveness of two methods of telerehabilitation (TR) delivery: mobile health TR (mHealth-TR) and video conference TR (VC-TR) in improving outcomes for patients with RC tendinopathy.MethodsEighty-five participants diagnosed with RC tendinopathy were randomized into synchronous (VC-TR) and asynchronous (mHealth-TR) groups. Both groups received an identical 8-week exercise programme delivered through their assigned platform. The programme included scapular mobilization, range-of-motion, strengthening, and stretching exercises. The primary outcomes were pain level (Visual Analogue Scale [VAS]), disability (Disabilities of the Arm, Shoulder and Hand [DASH] score), quality of life (Short Form-36 Health Survey [SF-36] score), and shoulder mobility (universal goniometer). The assessments were carried out at baseline, after the treatment (week 8) and at a follow-up of 16 weeks.ResultsThe mean participant age was 51.8 years (SD 9.24), with 27% (n = 23) male. No significant between-group differences were observed for pain (VAS) or shoulder mobility (P > .05 for both). However, a significant group-by-time interaction effect was found for disability, measured by the DASH score (F(1,83) = 10.56, P = .001), and quality of life, measured by the SF-36 overall score (excluding physical role functioning, emotional role functioning, and social function) (Vitality/Energy: F(1,83) = 7.34, P = .006; Pain: F(1,83) = 4.78, P = .034; General Health: F(1,83) = 4.82, P = .032). Post-hoc analysis indicated significant improvements in disability and quality of life scores in the synchronous VC-TR group compared to the asynchronous mHealth-TR group. Specifically, DASH scores in the synchronous group decreased by 9.41 points (95% CI: 3.46 to 15.36, P = .002) from baseline to after treatment, and by 9.34 points (95% CI: 3.48 to 15.20, P = .002) by the 16th week. For quality of life, the VC-TR group showed significant improvements in the Vitality/Energy, Pain, and General Health domains from baseline to follow-up, with mean differences of 6.41, 11.68, and 10.83, respectively (all P < .05).DiscussionThis study suggests that patients with RC tendinopathy may experience greater improvements in pain management, disability, and overall quality of life through synchronous VC-TR compared to asynchronous mHealth-TR.

Thresholds for diminishing returns in postoperative range of motion after total shoulder arthroplasty

BACKGROUND

Satisfaction following total shoulder arthroplasty (TSA), which is commonly reported using patient-reported outcome measures (PROMs), is partially dependent upon restoring shoulder range of motion (ROM). We hypothesized there exists a minimum amount of ROM necessary to perform functional tasks queried in PROM questionnaires, beyond which further ROM may provide no further improvement in PROMs.

METHODS

A retrospective review of a multicenter international shoulder arthroplasty database was performed between 2004 and 2020 for patients undergoing anatomic or reverse TSA (aTSA, rTSA), with minimum 2-year follow-up. Our primary outcome was to determine the threshold in postoperative active ROM (abduction, forward elevation [FE], external rotation [ER], and internal rotation [IR] score), whereby additional improvement was not associated with additional improvement in PROMs (Simple Shoulder Test, American Shoulder and Elbow Surgeons score, and the Shoulder Pain and Disability Index). For comparison, we also evaluated the Shoulder Arthroplasty Smart (SAS) score, which is not subject to the ceiling effect.

RESULTS

We included 4459 TSAs (1802 aTSAs, 2657 rTSAs) with minimum 2-year follow-up (mean, 56 ± 32 months). The threshold in postoperative ROM that were associated with no further improvement were active abduction, 107-113° for PROMs vs. 163° for the SAS score; active FE, 149-162° for PROMs vs. 176° for the SAS score; active ER, 50-52° for PROMs vs. 72° for the SAS score; IR score, 4-5 points for all PROMs vs. 6 points for the SAS score. Out of 3508 TSAs with complete postoperative ROM data, 8.5% achieved or exceeded all ROM thresholds (14.5% aTSAs, 4.8% rTSAs).

CONCLUSIONS

Our findings demonstrate that postoperative ROM exceeding 113° of abduction, 162° of FE, 52° of ER, and IR to L1 is associated with minimal additional improvement in PROMs. While individual patient needs vary, the thresholds may provide helpful targets for patients undergoing postoperative rehabilitation.

Cardio-Respiratory, Functional and Antalgic Effects of the Integrated Thermal Care Protocol After Breast Cancer Surgery

BACKGROUND

In the cardio-respiratory rehabilitation field, thermal medicine represents an interesting complementary therapy approach. It can aid in complex medical contexts characterized by cardio-respiratory deficiency, functional limitation, and pain determined by the invasiveness of pharmacological and surgical treatments in combination with limited post-surgical physical activity.

METHODS

We investigated the evolution of cardio-respiratory and functional performances following the application of the Integrated Thermal Care (ITC) protocol in 11 mastectomized/quadrantectomized women (mean age of 54 years). The ITC protocol consisted of hydroponic treatments, steam inhalations treatment, hydrokinesitherapy, and manual treatments. Patients were assessed before and after a cycle of 1 h long treatment sessions, which were performed 5 days a week for 4 weeks. The outcomes were measured through the following scales and tests: Piper Fatigue Scale (PIPER), 6-Minute Walking Test (6MWT), Five Times Sit-to-Stand (5STS), Range of Arm Motion (ROM), Disability of the Arm-Shoulder-Hand Scale (DASH), and Numeric Pain Rating Scale (NPRS).

RESULTS

We found appreciable improvements in cardio-respiratory efficiency and in pain perception exemplified by a reduction of PIPER, 5STS, DASH, and NPRS values together with an increase in 6MWT and ROM values.

CONCLUSIONS

We conclude that ITC is a promising rehabilitative tool to enhance cardio-respiratory and functional performance and reduce pain after mastectomy/quadrantectomy.

Preoperative planning and inferior glenosphere overhang increases the odds of achieving high internal rotation after Univers reverse total shoulder arthroplasty

BACKGROUND

Despite advances in surgical technique and implant design, internal rotation (IR) after reverse total shoulder arthroplasty (rTSA) continues to be relatively unpredictable. The purpose of this study was to compare patient characteristics, use of 3-dimensional computed tomography (3D CT)-based preoperative planning, and postoperative implant position between patients with high or low IR after rTSA.

METHODS

A retrospective review was performed of a multicenter prospectively collected database on patients who underwent primary rTSA (Univers Revers; Arthrex, Inc.) from 2016-2021 with a minimum 2-year follow-up. Patients were selected for a comparative analysis who either achieved high IR (T12 or better) or low IR (below the hip) postoperatively. Baseline demographics and postoperative radiographs were evaluated for association with IR. Implant position was assessed on radiographs for lateralization shoulder angle (LSA), distalization shoulder angle (DSA), inferior glenosphere overhang, and coracoid-to-glenosphere distance. Regression analyses were performed on component and clinical variables to assess for factors predictive of high vs. low IR.

RESULTS

A total of 344 rTSAs were eligible, of which 98 patients met criteria for the high-IR group and 50 met criteria for the low-IR group. Decreased body mass index (BMI) (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.01-1.30, P = .044), high preoperative IR (OR 1.30, 95% CI 1.02-1.66, P = .034), and surgery on the dominant arm (OR 5.38, 95% CI 1.31-22.1, P = .019) correlated with an increased odds of high IR. The use of 3D CT-based preoperative planning was associated with having high IR (OR 9.69, 95% CI 1.83-51.3, P = .008). Radiographically, increased DSA (OR 1.09, 95% CI 1.02-1.16, P = .012) and increased inferior glenoid overhang (OR 1.39, 95% CI 1.07-1.80, P = .013) were associated with a greater chance of being in the high-IR group.

CONCLUSION

Although specific baseline patient characteristics influence the ability to obtain high IR after rTSA including increased preoperative IR, decreased BMI, and surgery on the dominant arm, there are several factors within the surgeon's control. The use of 3D CT-based preoperative planning greatly increases the odds of obtaining increased postoperative IR. More precisely, mindful implant positioning including inferior glenosphere overhang and slight distalization increased postoperative IR. Therefore, the use of 3D CT-based preoperative planning may be considered in order to carefully and consciously position the glenosphere to slightly increase distalization and inferior overhang in order to optimize IR. However, further evaluation with regard to 3D planned position and postoperative outcomes are required.

Shoulder Musculoskeletal Disorder Rehabilitation Using a Robotic Device Based on Electromyography (EMG) Biofeedback: A Retrospective Cohort Study

Background and Objectives: While shoulder injuries represent the musculoskeletal disorders (MSDs) most encountered in physical therapy, there is no consensus on their management. In attempts to provide standardized and personalized treatment, a robotic-assisted device combined with EMG biofeedback specifically dedicated to shoulder MSDs was developed. This study aimed to determine the efficacy of an 8-week rehabilitation program (3 sessions a week) using a robotic-assisted device combined with EMG biofeedback (RA-EMG group) in comparison with a conventional program (CONV group) in patients presenting with shoulder MSDs. Materials and Methods: This study is a retrospective cohort study including data from 2010 to 2013 on patients initially involved in a physical rehabilitation program in a private clinic in Chicoutimi (Canada) for shoulder MSDs. Shoulder flexion strength and range of motion were collected before and after the rehabilitation program. Forty-four patients participated in a conventional program using dumbbells (CONV group), while 73 completed a program on a robot-assisted device with EMG and visual biofeedback (RA-EMG group); both programs consisted of two sets of 20 repetitions at 60% of maximal capacity. Results: We showed that the RA-EMG had significantly greater benefits than the CONV group for shoulder flexion strength (4.45 [2.6;6.15] kg vs. 2.3 [0.90;4.775] kg, U = 761, p = 0.013) and for normalized strength (77.5 [51.3;119.1] % vs. 39.1 [16.6;89.2] %, U = 755, p = 0.016). In addition, the RA-EMG group showed a trend to greater absolute gain of ROM than the CONV group (10.0 [0;24.3] degrees vs. 5.5 [0;12.0] degrees, U = 1931, p = 0.067), and a greater benefit in normalized ROM was observed for the RA-EMG (7.4. [0;17.7] %) than the CONV group (4.6 [0;10.8], U = 1907, p = 0.046). Conclusions: The current retrospective cohort study showed that a specific and tailored 8-week rehabilitation program with constant effort by automatic adjustment of the level of resistance by EMG feedback induced greater benefits for shoulder flexion strength and a trend to improve range of motion compared to conventional rehabilitation in patients with shoulder MSDs. Future research should be pursued to determine the added potential of this approach for abduction and external rotation with a randomized controlled design.

Kinematic analysis of upper limb fractures: Insights for rehabilitation strategies

BACKGROUND

Upper limb fractures significantly alter movement, impacting function and recovery. Three-dimensional motion analysis allows precise assessment of these changes.

METHODS

Sixty patients were divided into four groups: shoulder, elbow, wrist fractures, and controls. Functional assessment was performed using the DASH questionnaire, followed by three-dimensional kinematic analysis with eight Oqus 300 cameras and 14 reflective markers on the thorax, scapula, humerus, forearm, and hand. The Acromion Marker Cluster method was used for accurate scapular tracking. Tasks analyzed included hand on shoulder, hand on back, and hand on neck. All measured variables are expressed in degrees. The analysis focused on the differences in maximum joint angles for each degree of freedom across the tasks. These differences were assessed using MANOVA, followed by ANOVAs and Tukey's post hoc test when applicable.

FINDINGS

Significant kinematic differences were observed between the fracture groups and the control group across all tasks. Shoulder fracture patients exhibited the greatest reductions in humeral flexion and abduction. Elbow fracture patients showed the most restricted elbow flexion. Wrist fracture patients presented significantly reduced radial/ulnar deviation. These movement impairments were observed across all tasks, with the most pronounced limitations seen in the hand-to-shoulder task. Effect sizes (η2) indicated clinically meaningful impacts, particularly for shoulder and wrist movements.

INTERPRETATION

This study reveals distinct kinematic alterations following upper limb osteosynthesis, emphasizing the need for individualized rehabilitation strategies addressing these specific movement impairments to optimize recovery.

Assessment of upper extremity functional capacity in following osteosynthesis for upper limb fractures using a novel method for determining total reachable workspace

Objective

This study aimed to assess reachable workspace (RWS) in patients post-osteosynthesis of shoulder, elbow, or wrist fractures and explore correlations with self-reported function and kinesiophobia.

Design

An observational case-control study compared patients with fractures to a control group, utilizing questionnaires and 3D kinematic data.

Participants

The sample included 66 individuals who had undergone osteosynthesis: 21 with shoulder fractures, 10 with elbow fractures, and 22 with wrist fractures. A control group of 23 participants without upper limb pathologies was also established. Inclusion criteria were ages 18-80 and recent surgery; exclusions were previous upper limb surgeries, cervical pathologies, systemic diseases or nerve injuries.

Main outcome measure

RWS, the three-dimensional volume the hand can reach, was measured with participants standing. Kinesiophobia was assessed using the Tampa Scale of Kinesiophobia (TKS), and physical disability and pain were measured using the DASH questionnaire and the Numeric Pain Rating Scale (NPRS).

Results

Fracture groups exhibited significant RWS reductions (62-85%) compared to the control group, with no significant differences among the fracture types. RWS showed a high correlation with TKS (R = 0.77) and a moderate correlation with DASH (R = 0.52).

Conclusion

RWS is a promising biomechanical parameter for assessing upper limb function post-fracture, aiding in refining rehabilitation protocols.

Is There an Association Between Postoperative Internal Rotation and Patient-reported Outcomes After Total Shoulder Arthroplasty?

BACKGROUND

Deficient internal rotation after shoulder arthroplasty can inhibit specific essential activities of daily living that require behind-the-back arm positioning. Although postoperative internal rotation deficits occur, their impact on outcomes of total shoulder arthroplasty (TSA) is not well established. Previous authors have validated the Single Assessment Numeric Evaluation (SANE) as a patient-reported assessment of acceptable outcomes of TSA.

QUESTIONS/PURPOSES

(1) Is there an association between postoperative internal rotation and acceptable outcomes following TSA as assessed by SANE? (2) Is there a threshold for internal rotation after TSA beyond which increasing internal rotation no longer improves odds of acceptable outcomes?

METHODS

A single institution's longitudinally maintained shoulder arthroplasty registry was used to identify patients undergoing primary anatomic or reverse TSA (RTSA). The registry provides postoperative patient-reported outcomes, including SANE scores. Postoperatively, patients complete a previously validated ROM self-assessment to quantify their current abduction, forward elevation, external rotation in adduction and abduction, and internal rotation in adduction. Data on patient age, preoperative Patient-Reported Outcomes Measurement Information System mental health scores, gender, surgery performed, and hand dominance were also obtained. In all, 784 patient-reported surveys were available. Thirty-four percent (268 of 784) of the surveys were collected at 1 year, 52% (410 of 784) at 2 years, 11% (87 of 784) at 5 years, and 2% (19 of 784) at 10 years. More than 50% percent (446 of 784) of patients underwent RTSA, 48% were men, and the mean ± SD age was 68 ± 8 years at the time of surgery. A logistic multivariate analysis was used to assess the association of internal rotation with an acceptable outcome (defined as a SANE score of > 75%). A receiver operating characteristic curve was used to assess an internal rotation threshold associated with an acceptable SANE score.

RESULTS

After accounting for age, gender, hand dominance, pain level, and surgical procedure, patients with internal rotation below the upper back had lower odds of achieving a SANE score of > 75% (p < 0.05). The threshold for SANE scores > 75% was identified to be internal rotation to the midback and higher, resulting in an area under the curve of 0.71 (95% CI 0.67 to 0.75; p < 0.001) with sensitivity of 57% (95% CI 0.56 to 0.58) and specificity of 75% (95% CI 0.73 to 0.77).

CONCLUSION

After shoulder arthroplasty, shoulder normalcy was associated with postoperative internal rotation. Although our study has not proven a causal relationship between limited internal rotation and poorer SANE scores, our clinical experience combined with these findings suggests that limited internal rotation indeed is likely clinically important in this context, and so addressing postoperative internal rotation deficits, especially for RTSA, may improve the quality of shoulder arthroplasty. Further research is needed to understand the modifiable factors that prevent sufficient internal rotation following shoulder arthroplasty.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Lower trapezius tendon transfer for massive irreparable rotator cuff tears improves outcomes in patients with high grade fatty infiltration of teres minor

Background

This study compares postoperative outcomes of lower trapezius tendon transfers (LTTTs) in massive irreparable rotator cuff (RC) tears based on the degree of teres minor (TM) fatty infiltration.

Methods

In this prospective longitudinal observational study, patients with massive RC tears undergoing arthroscopic-assisted LTTT by two surgeons were screened. TM fatty infiltration on preoperative magnetic resonance imaging was graded using the Goutallier classification. Two groups were created as follows: group A included grades 0 and 1 (no or little fatty infiltration), and group B included grades 2 to 4 (moderate-to-severe fatty infiltration). Participants completed the Single Assessment Numeric Evaluation (SANE) score preoperatively, and 12- and/or 24 months postoperatively along with a clinical assessment. Independent t-tests compared groups, and paired t-tests compared pre-vs. postoperative results. Significance was defined as P < .05.

Results

There were 47 patients in group A and 19 in group B. No group differences were found in preoperative SANE score, forward elevation or active external rotation (ER). Both groups showed significant postoperative improvements in SANE score with no differences between the groups. An ER lag sign was observed in 18/47 patients (38.3%) in group A and 11/19 patients (57.9%) in group B (P = .177). Preoperative ER strength was significantly different in group A (2.9 kg) vs. group B (0.7 kg; P = .001), but postoperative ER strength was similar (P = .931).

Conclusion

LTTT is a suitable salvage procedure regardless of the degree of TM fatty infiltration and should be considered an alterative procedure to latissimus dorsi tendon transfer in patients with high-grade TM fatty infiltration.

Therapeutic arthroscopy for noninfectious stiffness and anterior shoulder pain after reverse shoulder arthroplasty leads to clinical improvement in most patients with a low complication rate

BACKGROUND

Reverse shoulder arthroplasty (RSA) exhibits favorable outcomes in managing rotator cuff arthropathy, primary glenohumeral arthritis, and complex proximal humeral fractures. Despite its success and reliability, certain patients experience persistent pain and stiffness. The clinical utility of therapeutic arthroscopy in RSA patients remains an area for investigation. The purpose of this study was to report clinical outcomes, including patient-reported outcomes (PROs), range of motion (ROM), and satisfaction, in patients who underwent therapeutic arthroscopy for noninfectious stiffness and subcoracoid impingement following RSA. The hypothesis was that patients would experience clinical improvement and satisfaction, with earlier intervention being superior to later intervention.

METHODS

Multicenter retrospective review on patients who underwent therapeutic arthroscopy for noninfectious stiffness and anterior shoulder pain following RSA with minimum 1-year follow-up. PROs and ROM were collected preoperatively and postoperatively. Subjective improvement in ROM and pain, complications, satisfaction, and return to activities were recorded. Data was stratified into 2 cohorts based on timing of RSA to arthroscopy (1 year or less was considered early intervention and >1 year late intervention) and variables were analyzed for each cohort.

RESULTS

A total of 19 patients met the study criteria (13 patients in early intervention cohort, 6 in late intervention cohort). The average time from the index surgery to arthroscopy was 7.7 ± 2.1 months in the early intervention cohort and 28.3 ± 10.3 months in the late intervention cohort (P = .004). The overall cohort improved significantly regarding pain (Visual Analog Scale [VAS]: Δ-1.1, P = .003), ROM (forward flexion [FF]: Δ21°, P = .002; external rotation: Δ14°, P = .010; internal rotation: Δ1 spinal level, P = .023) and PROs (American Shoulder and Elbow Surgeons: Δ18.2, P = .001; Subjective Shoulder Value: Δ16.3, P = .009). The early intervention cohort demonstrated significant improvement in VAS (Δ-1.1, P = .029), American Shoulder and Elbow Surgeons (Δ16.2, P = .013), Subjective Shoulder Value (Δ18.5, P = .008), FF (Δ23°, P = .016), and external rotation (Δ15°, P = .028). The late intervention cohort had significant improvement in VAS (Δ-1.3, P = .048) and FF (Δ17°, P = .017). Seventy-four percent of patients in the overall cohort reported decreased pain, 79% improvement in ROM, 68% returned to activities, and 74% were satisfied. There were no complications.

CONCLUSION

Therapeutic arthroscopy for noninfectious stiffness and anterior shoulder pain following RSA improves clinical outcomes in most patients with a low complication risk. Although postoperative outcomes were comparable between groups, functional improvement was more likely in patients who underwent intervention earlier.

Predictors of Internal Rotation-Dependent Activities of Daily Living Performance and Favorable Satisfaction Despite Loss of Objective Internal Rotation After Reverse Shoulder Arthroplasty

INTRODUCTION

Previous research has determined that objective and subjective internal rotation (IR) may be discordant. The purpose of this study was to identify predictors of patient-reported ability to perform IR-dependent activities of daily living (IRADLs) and favorable patient satisfaction after reverse shoulder arthroplasty (RSA) despite the loss of objective IR.

METHODS

A single, institutional, shoulder arthroplasty database was queried for patients undergoing primary RSA with a minimum 2-year follow-up. Patients who were wheelchair bound or had a preoperative diagnosis of infection, fracture, or tumor were excluded. We first identified patients in the overall cohort that lost objective IR from pre- to postoperative assessment, defined as a one-point reduction in the eight-point Flurin scale. In this cohort, we identified patient characteristics that were predictive of patient-reported ability to perform IRADLs and overall patient satisfaction and thresholds in postoperative objective IR.

RESULTS

Out of 599 RSAs initially identified, 107 RSAs lost objective IR (45% female, mean age 70 years). On average, patients lost 1.7 IR score points pre- to postoperatively. Greater preoperative IR and lesser loss of objective IR pre- to postoperatively were associated with greater patient-reported ability to perform all 4 IRADLs (odds ratio 1.54 to 2.5), whereas female sex was associated with worse patient-reported ability to perform 3 IRADLs (odds ratio 0.26 to 0.36). We identified that patients with postoperative IR below the sacrum were unlikely to be able to perform IRADLs and those with postoperative IR at or above L4-L5 were likely to be satisfied.

CONCLUSION

Despite losing objectively assessed IR after RSA, many patients are still able to perform IRADLs and report favorable satisfaction as long as objective IR reaches L4/5. Female sex and postoperative IR below the sacrum were associated with the inability to perform IRADLs, whereas postoperative IR to or above L4-L5 was associated with subjective ratings of satisfaction.

Sling and forget it? A systematic review of operative versus nonoperative outcomes for scapula fractures

BACKGROUND

The majority of scapula fractures have historically been treated nonoperatively. The current literature describing patient outcomes following scapula fractures is limited. Our objective was to determine differences in outcomes between operatively and nonoperatively treated scapular fractures. The goal of our study was to provide an updated and comprehensive systematic review for scapula body, neck, and glenoid fractures focusing on several outcomes including union rate, return to work, pain, shoulder active range of motion, strength, functional scores, and any recorded complication.

METHODS

The PRISMA methodology was followed for this systematic review. Articles were obtained from the PubMed/Medline database using the following search terms: scapula body OR scapula neck OR intra-articular glenoid AND fracture. Additional articles were obtained by searching the bibliographies of included references. Studies were included if they contained clinical data on one or more of our study objectives and contained participants with a scapular body, neck, and/or glenoid fracture who were at least 16 year old. A total of 35 papers, with 822 total cases were included. Studies chosen were assessed for level of evidence and reviewed for data pertaining to the current study objectives. All cases of scapula fractures found throughout the literature were analyzed for outcome data. Outcomes studied included union rate, return to work, pain, shoulder active range of motion, strength, functional scores, and recorded complications.

RESULTS

The overwhelming majority of scapula fractures go on to union. The majority of patients will eventually return to work. Persistent postinjury pain is unfortunately common. Shoulder range of motion and strength are decreased when compared to the contralateral shoulder. Nonoperative glenoid fractures have the lowest reported functional scores. Malunion, need for additional surgeries, and post-traumatic arthritis were the most common complications.

CONCLUSION

When treating scapula fractures, orthopedic surgeons must consider the specific fracture pattern, as well as patient specific goals. Risks and benefits of both operative and nonoperative management should be discussed with the patient including the exceptionally low nonunion rate regardless of treatment option and that persistent pain following injury is unfortunately common.

Musculoskeletal ultrasound of the shoulder in patients with adhesive capsulitis

Adhesive capsulitis is a common pathological condition of the shoulder that affects the general population. The aim of the present study was to explore shoulder ultrasonographic findings in patients with adhesive capsulitis. A cross-sectional descriptive study was conducted on 96 patients with adhesive capsulitis. Abnormal shoulder ultrasonographic findings were found in all participants. The top three abnormal ultrasonographic imaging features were biceps tendon effusion (71.8%), positive dynamic supraspinatus impingement (56.2%) and subdeltoid-subacromial bursitis (47.9%). By assessing the relationship between limited functional shoulder range of motion (ROM) and abnormal shoulder ultrasonographic findings, limited passive ROM (PROM) with shoulder flexion of ≤120 degrees was found to be significantly associated with positive dynamic supraspinatus impingement. Similarly, limited PROM in shoulder abduction of ≤130 degrees was found to be significantly associated with subdeltoid and subacromial bursitis, as well as positive dynamic supraspinatus impingement. In addition, limited PROM with shoulder internal rotation of ≤60 degrees was significantly associated with positive dynamic supraspinatus impingement. Varying abnormal shoulder ultrasonographic findings were obtained in patients with adhesive capsulitis. Therefore, it should be cautioned that relying solely on physical examination may not accurately indicate true shoulder pathology and it is suggested that the final diagnosis should be based on a combination of the patients' clinical and overall ultrasonographic findings.

Factors associated with subjective shoulder function preoperatively and postoperatively after arthroscopic rotator cuff repair

Background

Understanding factors associated with improvements in subjective shoulder function after arthroscopic rotator cuff repair (ARCR) helps clinicians identify targets for postoperative rehabilitation. The aim of this study was to investigate the factors associated with subjective shoulder function after ARCR.

Methods

Patients who underwent ARCR for rotator cuff tear with at least 12 months of follow-up were included. Subjective shoulder function was assessed preoperatively and at 6 and 12 months postoperatively, using the Shoulder36 (Sh36) 5 domain scores (pain, range of motion [ROM], strength, activities of daily living, and general health). Stepwise multivariable regression analysis was performed to extract the relevant factors for each Sh36 domain score using active shoulder ROM, isometric shoulder and elbow strength, pain score, demographic data, intraoperative findings, medical complications, and cuff integrity.

Results

A total of 104 patients met the inclusion criteria for this study. Multivariable regression analysis identified active abduction ROM as the factor associated with 5 Sh36 domain scores at preoperatively. At 6 months postoperatively, isometric external rotation strength at the body side or 90° abduction position, but not the ROM factor, was identified as a significant associated factor with 5 Sh36 domain scores. At 12 months postoperatively, pain score was the most associated factor with pain, ROM, strength, and activities of daily living domain scores of Sh36.

Conclusion

Factors associated with subjective shoulder function after ARCR differed between the preoperative and postoperative periods. Postoperative treatment, including rehabilitation, should be modified according to the postoperative period after ARCR.

Physiotherapist-supervised exercises versus physiotherapist-prescribed home exercises for treating partial thickness rotator cuff tears: a randomized controlled trial

BACKGROUND

Partial thickness rotator cuff tears significantly affect physical and psychosocial well-being. This study aimed to compare the efficacy of physiotherapist-supervised exercise and physiotherapist-prescribed home exercise programs on physical and psychosocial health measures in partial thickness rotator cuff tears.

METHODS

Seventy patients with partial thickness rotator cuff tears (44 female; mean age, 50.1 ± 5.2 years) were divided into 2 groups. Both the physiotherapist-supervised exercise group (group 1, n = 35) and physiotherapist-prescribed home exercise group (group 2, n = 35) received a program consisting of glenohumeral joint range of motion, stretching, and strengthening exercises (twice a week for eight weeks). The primary outcome measures were the modified Constant-Murley Score (mCMS) and the Hospital Depression and Anxiety Scale. Secondary outcome measures were the visual analog scale, active range of motion (AROM), Pain Catastrophizing Scale, Pittsburg Sleep Quality Index, Short Form-12, and Global Rating of Change Scale. Patients were assessed at baseline and the end of the treatment. The significance level was adjusted to 0.025 after the Bonferroni correction.

RESULTS

Both groups showed significant improvements in all measures after treatment. There were no statistically significant group-by-time interactions for the mCMS (F = 12.47, P = .03) and the Hospital Depression and Anxiety Scale (F = 0.89, P = .14 for depression; F = 0.73, P = .44 for anxiety). However, the improvement in the mCMS was clinically meaningful in both groups. The overall group-by-time interaction was significant for the visual analog scale activity (P = .004), shoulder flexion (P = .01) and abduction (P = .02) AROM, and Pain Catastrophizing Scale (P = .005) in favor of group 1.

CONCLUSION

Exercise effectively improves physical and psychosocial health measures in partial thickness rotator cuff tears when delivered in the clinic or at home. However, exercise is more effective for activity pain, AROM, and pain catastrophizing when delivered in the clinic, highlighting the effectiveness of the physiotherapist-supervised exercise program.

Home-based guidance training system with interactive visual feedback using kinect on stroke survivors with moderate to severe motor impairment

The home-based training approach benefits stroke survivors by providing them with an increased amount of training time and greater feasibility in terms of their training schedule, particularly for those with severe motor impairment. Computer-guided training systems provide visual feedback with correct movement patterns during home-based training. This study aimed to investigate the improvement in motor performance among stroke survivors with moderate to severe motor impairment after 800 min of training using a home-based guidance training system with interactive visual feedback. Twelve patients with moderate to severe stroke underwent home-based training, totaling 800 min (20-40 min per session, with a frequency of 3 sessions per week). The home-based guidance training system uses Kinect to reconstruct the 3D human body skeletal model and provides real-time motor feedback during training. The training exercises consisted of six core exercises and eleven optional exercises, including joint exercises, balance control, and coordination. Pre-training and post-training assessments were conducted using the Fugl-Meyer Assessment-Upper Limb (FMA-UE), Fugl-Meyer Assessment-Lower Limb (FMA-LE), Functional Ambulation Categories (FAC), Berg Balance Scale (BBS), Barthel Index (BI), Modified Ashworth Scale (MAS), as well as kinematic data of joint angles and center of mass (COM). The results indicated that motor training led to the attainment of the upper limit of functional range of motion (FROM) in hip abduction, shoulder flexion, and shoulder abduction. However, there was no improvement in the active range of motion (AROM) in the upper extremity (U/E) and lower extremity (L/E) joints, reaching the level of the older healthy population. Significant improvements were observed in both left/right and superior/inferior displacements, as well as body sway in the mediolateral axis of the COM, after 800 min of training. In conclusion, the home-based guidance system using Kinect aids in improving joint kinematics performance at the level of FROM and balance control, accompanied by increased mediolateral body sway of the COM for stroke survivors with moderate to severe stroke. Additionally, spasticity was reduced in both the upper and lower extremities after 800 min of home-based training.

The effects of tears in infraspinatus on other rotator cuff constituents

The rotator cuff tear effects on glenohumeral joint tissues, such as superior labrum anterior-posterior (SLAP) lesions, have been studied experimentally or numerically in various cases. In relation to these studies, and as a novel feature of our study, infraspinatus (INF) muscle tear effects on other muscle force variations and stress and strain increases on glenoid labrum (GL), glenoid cartilage (GC) tissues, and a SLAP pathology were investigated. The ITK-SNAP Software (ISS) was used to segment the humerus and glenoid bone. The surface entities were segmented and exported to SolidWorks 2019, where the finite element model (FEM) was completed. Static optimizations of the muscle forces were calculated using a generic model in OpenSim 4.1 for the 0-3.88 s time interval to perform our finite element analyses (FEAs) in ANSYS 19.3 for the intact, partial torn, and fully torn INF muscle. The FEAs were also conducted for the specified time interval. The stress and strain increases on the GL, and GC tissues were determined to be critical when compared with yield strengths. In the case of fully torn INF, the GL and cartilage interfacial principal stress was calculated to be 3.3856 MPa. In the case of the fully torn INF, the principal stress that occurred on the GC tissue was calculated to be 42.465 MPa. In the case of the intact INF, the principal stress that occurred on the labrum was obtained as 4.257 MPa. These results showed that there was no detachment or disorder on the designated tissues caused by the INF muscle tear when the shoulder functioned at 60° of external rotation at 11° of abduction. Nonetheless, a minor amount of external force could cause severe pathological effects on the specified tissues.

General Muscle Torque Generator Model for a Two Degree-of-Freedom Shoulder Joint

Muscle torque generators (MTGs) have been developed as an alternative to muscle-force models, reducing the muscle-force model complexity to a single torque at the joint. Current MTGs can only be applied to single Degree-of-freedom (DoF) joints, leading to complications in modeling joints with multiple-DoFs such as the shoulder. This study aimed to develop an MTG model that accounts for the coupling between 2-DoF at the shoulder joint: shoulder plane of elevation (horizontal abduction/adduction) and shoulder elevation (flexion/extension). Three different 2-DoF MTG equations were developed to model the coupling between these two movements. Net joint torques at the shoulder were determined for 20 participants (10 females and 10 males) in isometric, isokinetic, and passive tests. Curve and surface polynomial fitting were used to find the best general fit for the experimental data in terms of the different degrees of coupling. The models were validated against experimental isokinetic torque data. It was determined that implicit coupling that used interpolation between single-DoF MTGs resulted in the lowest root-mean-square percent error of 8.5%. The work demonstrated that general MTG models can predict torque results that are dependent on multiple-DoFs of the shoulder.

Passive shoulder abduction range of motion at 3 months postoperatively is the most important prognostic factor for achieving full recovery of range of motion at 6 months after arthroscopic rotator cuff repair

Background

After arthroscopic rotator cuff repair (ARCR), it is crucial for clinicians to predict the functional recovery in the early postoperative period for considering rehabilitation strategies. The aim of this study was to identify the prognostic factors in the early postoperative period for achieving full recovery of range of motion (ROM) at 6 months after ARCR.

Methods

This study included 184 patients who underwent ARCR. Patients were divided into the full recovery and nonrecovery groups using the Constant ROM score at 6 months postoperatively. The area under the curve for predicting the full recovery group was calculated for all independent variables such as demographic data, ROM, shoulder functional scores at preoperative and 3 months postoperative using receiver operating characteristic curve analysis. Multivariable logistic regression analysis was then performed using candidate variables with an area under the curve of 0.7 or greater to determine prognostic factors for full recovery at 6 months postoperatively. The same analysis as above was also performed by dividing the patients into groups according to their preoperative ROM.

Results

Multivariable logistic regression analysis revealed that preoperative active flexion, 3 months postoperative passive abduction, and internal rotation at 90° abduction ROM were significant prognostic factors of achieving full ROM recovery at 6 months postoperatively. Only passive abduction ROM at 3 months postoperatively was significantly extracted in the preoperative ROM limitation group.

Conclusion

This study demonstrated that passive abduction ROM at 3 months postoperatively was a significant prognostic factor of achieving full recovery of ROM at 6 months after ARCR.

Understanding overall shoulder function and health: the value of specific quantitative vs. qualitative shoulder range of motion on patient-reported outcome measures

HYPOTHESIS AND BACKGROUND

It is known that, though widely used, shoulder range of motion (ROM) measurements are not standardized and have a high rate of intra- and interobserver differences. Particularly, the inconsistency in quantitative and qualitative measurements and their relationship to patient-reported outcome measures (PROMs) make shoulder health difficult to determine.

METHODS

This was a prospective study of 147 patients who presented with a chief complaint of shoulder pain to the orthopedic sports medicine and shoulder clinic of a single fellowship-trained surgeon. Measured by 1 examiner, quantitative ROM measurements were taken with a goniometer and qualitative ROM measured by the anatomic level that the patient could reach. The following PROMs were used as well: American Shoulder and Elbow Surgeons shoulder score, Single Assessment Numeric Evaluation, Shoulder Pain and Disability Index, Oxford Shoulder Score, Disabilities of the Arm, Shoulder, and Hand questionnaire, 12-Item Short Form Health Survey, and Patient-Reported Outcomes Measurement Information System pain interference short form 6a (PROMIS 6a). Statistical analysis was performed with SPSS using the Pearson correlation and 2-sample t test. The Benjamini-Hochberg correction was used to determine the P value at which statistical significance was reached to correct for multiple comparisons.

RESULTS

Qualitative internal rotation (IR) (the hand behind back reach test) and qualitative forward flexion (FF) correlated with all goniometer angle measurements and PROMs (both shoulder and general health scores). These qualitative measures proved to be an appropriate proxy for IR and FF goniometer measurements. Qualitative external rotation (ER) was not a good substitute for quantitative ER measurement. Quantitative ER correlated with all PROMs. As ROM increased when measured by quantitative ER, qualitative IR, and qualitative FF, shoulder and general health PROMs incrementally increased as well.

DISCUSSION/CONCLUSIONS

Qualitative IR measurement, the hand-behind-back reach test, is an adequate substitution for IR goniometer angle as well as a strong representation of global shoulder ROM, shoulder health, and general health while factoring in patient age. Qualitative FF measurement is also an appropriate proxy for quantitative FF and represents global shoulder and general health without factoring in age. Quantitative ER, via goniometer angle, is a better assessment of the shoulder than qualitative ER and is a representation of overall shoulder and general health. We recommend the use of quantitative ER, qualitative IR, and qualitative FF measurements to best understand a patient's overall shoulder health and its impact on their overall health.

Long-term outcomes of pectoralis major transfer for scapular winging due to long thoracic nerve palsy: results after a median follow-up of 17 years

Background

A pectoralis major (PM) transfer is a viable treatment option for patients with scapular winging due to long thoracic nerve (LTN) palsy not responding to nonsurgical management. However, the long-term outcomes remain unknown. Therefore, the purpose of this study was to evaluate the long-term outcome of shoulder function (ie, minimum follow-up of 10 years) and quality-of-life (QoL) of patients treated for scapular winging due to LTN palsy with a PM transfer.

Methods

This observational cohort study included 15 patients (16 shoulders) who underwent PM transfer, using a tendoachilles allograft, between 1995 and 2012. Shoulder forward flexion and abduction were analyzed preoperatively, 1 year after surgery and at the final follow-up. SF-36 component scores (physical component summary (PCS) and mental component summary (MCS)) were used to evaluate the QoL.

Results

Shoulder forward flexion and abduction measured in degrees improved from 86 (SD 14.5) and 82 (SD 33.8) preoperatively to 140 (SD 27.3) and 138 (31.3) at 1 year postoperatively. After a median follow-up of 17 years, mean shoulder functions were slightly lower than at 1 year postoperatively, but still better than preoperative function, ie, forward flexion 121 (SD 41.9) and abduction 122 (SD 44.5). The mean PCS score at the final follow-up was 41.9 (SD 9.7), and the mean MCS score was 49.9 (SD 12.5). Better shoulder function at the final follow-up was significantly associated with higher QoL in terms of PCS scores (P = .023), but not MCS scores (P = .287).

Conclusion

The results of the present study indicate that PM transfer augmented with an achilles tendon allograft for scapular winging due to LTN palsy leads to functional improvements that persist in long term. These functional improvements likely translate to better QoL based on their association.

Engineering an extracellular matrix-functionalized, load-bearing tendon substitute for effective repair of large-to-massive tendon defects

A significant clinical challenge in large-to-massive rotator cuff tendon injuries is the need for sustaining high mechanical demands despite limited tissue regeneration, which often results in clinical repair failure with high retear rates and long-term functional deficiencies. To address this, an innovative tendon substitute named "BioTenoForce" is engineered, which uses (i) tendon extracellular matrix (tECM)'s rich biocomplexity for tendon-specific regeneration and (ii) a mechanically robust, slow degradation polyurethane elastomer to mimic native tendon's physical attributes for sustaining long-term shoulder movement. Comprehensive assessments revealed outstanding performance of BioTenoForce, characterized by robust core-shell interfacial bonding, human rotator cuff tendon-like mechanical properties, excellent suture retention, biocompatibility, and tendon differentiation of human adipose-derived stem cells. Importantly, BioTenoForce, when used as an interpositional tendon substitute, demonstrated successful integration with regenerative tissue, exhibiting remarkable efficacy in repairing large-to-massive tendon injuries in two animal models. Noteworthy outcomes include durable repair and sustained functionality with no observed breakage/rupture, accelerated recovery of rat gait performance, and >1 cm rabbit tendon regeneration with native tendon-like biomechanical attributes. The regenerated tissues showed tendon-like, wavy, aligned matrix structure, which starkly contrasts with the typical disorganized scar tissue observed after tendon injury, and was strongly correlated with tissue stiffness. Our simple yet versatile approach offers a dual-pronged, broadly applicable strategy that overcomes the limitations of poor regeneration and stringent biomechanical requirements, particularly essential for substantial defects in tendon and other load-bearing tissues.

The Feasibility and Efficacy of Remote App-Guided Home Exercises for Frozen Shoulder: A Pilot Study

Home exercise programs are beneficial in managing frozen shoulder (FS), yet adherence remains challenging. This pilot study introduces the remote app, Defrozen, designed for home exercises and assesses its feasibility and clinical outcomes in FS patients undergoing intra-articular and sub-acromial corticosteroid treatment. Over a four-week period, patients used the Defrozen-app, engaging in guided exercises. The feasibility of the intervention was assessed through several measurement scales, including adherence, the Technology Acceptance Model 2 (TAM2), the System Usability Scale (SUS), and User Satisfaction and Engagement (USE). Clinical outcomes included pain scale, Oxford Shoulder Score (OSS), Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) Score, and passive range of motion. The TAM2 results indicated high perceived usefulness (4.5/5), ease of use (4.8/5), and intention to use (4.4/5); the SUS score was high at 81.7/100, complemented by USE scores reflecting ease of learning (4.9/5) and satisfaction (4.3/5). Clinical outcomes showed significant pain reduction, improved shoulder function, reduced shoulder-related disability, and increased shoulder range of motion. These findings suggest the Defrozen-app as a promising solution for FS, significantly improving adherence and showing potential to enhance clinical outcomes. However, these clinical outcome results are preliminary and necessitate further validation through a large-scale randomized controlled trial to definitively confirm efficacy and assess long-term benefits.

Evaluating the effects of two different kinesiology taping techniques on shoulder range of motion and proprioception in patients with hypermobile Ehlers-Danlos syndrome: a randomized controlled trial

Background

Ehlers-Danlos syndrome (EDS) is a common group of inherited connective tissue disorders with a prevalence as high as 0.75%-2% of the population. Physical manifestations include pain and decreased proprioception, especially in more mobile joints, such as the shoulder. The kinesiology tape (K-Tape) is often used to treat patients with shoulder dysfunction. The effectiveness of the K-Tape is uncertain, and there is a lack of studies specifically studying the K-Tape in an EDS population.

Purpose

The purpose of this study was to compare the short-term effects of two different K-Tape procedures on shoulder active joint reposition (AJR) and active range of motion (AROM) in patients with hypermobile EDS (hEDS) and shoulder pain.

Methods

All participants were recruited from the EDS support groups and presented with shoulder pain. Baseline demographic information was obtained for each participant, after which AROM and AJR were assessed. The participants were randomized to receive one of two K-Tape procedures. Testing was repeated immediately post-taping and 48 h post-taping.

Results

Significant improvements in shoulder external (F = 10.917, p < 0.001) and internal (F = 11.736, p < 0.001) rotations were seen from baseline to immediately post-taping and baseline to 48 h post-taping in the experimental K-Tape group. There were no significant differences in the shoulder rotation in the control K-Tape group and no significant differences in either group for shoulder flexion or AJR at any time point (p > 0.05).

Conclusion

K-Tape may offer short-term improvements in shoulder rotation AROM in patients with hEDS and shoulder pain.

Predictive factors influencing internal rotation following reverse total shoulder arthroplasty

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) is increasingly used as a treatment modality for various pathologies. The purpose of this review is to identify preoperative risk factors associated with loss of internal rotation (IR) after RTSA.

METHODS

A systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Ovid MEDLINE, Ovid Embase, and Scopus were queried. The inclusion criteria were as follows: articles in English language, minimum 1-year follow-up postoperatively, study published after 2012, a minimum of 10 patients in a series, RTSA surgery for any indication, and explicitly reported IR. The exclusion criteria were as follows: articles whose full text was unavailable or that were unable to be translated to English language, a follow-up of less than 1 year, case reports or series of less than 10 cases, review articles, studies in which tendon transfers were performed at the time of surgery, procedures that were not RTSA, and studies in which the range of motion in IR was not reported.

RESULTS

The search yielded 3792 titles, and 1497 duplicate records were removed before screening. Ultimately, 16 studies met the inclusion criteria with a total of 5124 patients who underwent RTSA. Three studies found that poor preoperative functional IR served as a significant risk factor for poor postoperative IR. Eight studies addressed the impact of subscapularis, with 4 reporting no difference in IR based on subscapularis repair and 4 reporting significant improvements with subscapularis repair. Among studies with sufficient power, BMI was found to be inversely correlated with degree of IR after RTSA. Preoperative opioid use was found to negatively affect IR. Other studies showed that glenoid retroversion, component lateralization, and individualized component positioning affected postoperative IR.

CONCLUSIONS

This study found that preoperative IR, individualized implant version, preoperative opioid use, increased body mass index and increased glenoid lateralization were all found to have a significant impact on IR after RTSA. Studies that analyzed the impact of subscapularis repair reported conflicting results.

Achieving satisfactory functional outcomes in conservatively treated proximal humerus fractures: relationship between shoulder range of motion and patient-reported clinical outcome scores

Background

Proximal humerus fractures are common osteoporotic fractures. Postinjury outcome measures include objective clinician-measured range of motion (ROM) and subjective patient-reported outcome measures (PROMs), but the relationship between both has not been established. This study aimed to determine the relationship between shoulder ROM and PROMs and establish which ROMs correlated most with PROMs.

Methods

A prospective cohort study was conducted on patients with acute proximal humerus fractures. Surgical intervention, open or pathological fractures, neurovascular compromise, polytrauma, or delayed presentations were excluded. Correlation and regression analyses between active ROM and PROMs (Quick Disabilities of Arm, Shoulder and Hand [QuickDASH] and Oxford Shoulder Score [OSS]) at 1-year postinjury were explored. ROM cutoffs predicting satisfactory PROM scores were established.

Results

Fifty-five patients were recruited. Moderate correlations were observed between PROMs and flexion, extension, and abduction, but not internal and external rotation. Multivariate analysis showed significant relationships between PROMs and flexion [QuickDASH: adjusted coefficient (AC): -0.135, P = .013, OSS: AC: 0.072, P = .002], abduction [QuickDASH: AC: -0.115, P = .021, OSS: AC: 0.059, P = .005], and extension [QuickDASH: AC: -0.304, P = .020] adjusting for age, gender, Neer classification, injury on dominant side, and employment. Achieving 130° flexion, 59° extension, and 124° abduction were correlated with satisfactory OSS/QuickDASH scores, respectively.

Conclusion

Overall, holistic assessment of outcomes with both subjective and objective outcomes are necessary, as shoulder flexion, extension, and abduction are only moderately correlated with PROMs. Attaining 130° flexion, 59° extension, and 124° abduction corresponded with satisfactory functional outcomes measured by OSS/QuickDASH and can guide rehabilitation.

A systematic review of the treatment of distal humerus fractures in older adults: A comparison of surgical and non-surgical options

Background

Fractures of the distal humerus are a common fragility fracture in older adults. The purpose of this study was to systematically review the literature to produce pooled estimates of the outcomes of treatment using total elbow arthroplasty (TEA), open reduction and locking plate fixation (ORIF), hemiarthroplasty or with conservative management.

Methods

A systematic review of PUBMED and EMBASE databases was conducted for studies reporting outcomes of intra-articular fractures in older adults. Data extracted included patient-reported outcome measures as well as clinical outcomes including ROM, adverse events and all-cause reoperation rates.

Results

Forty-eight studies met the inclusion criteria and included 1838 acute, intra-articular distal humeral fractures. There was no clinically important difference in patient-reported pain and function measured on the Mayo Elbow Performance Score (TEA = 89.3 (SD 20.0), Hemi = 88.4 (SD 10.6), internal fixation = 85.0 (SD 14.7), non-operative = 85.1 (SD 11.0)).

Discussion

Each of the treatment modalities studies resulted in a reasonable level of elbow function. The included studies were largely non-comparative and at considerable risk of bias. As elbow replacement surgery becomes centralised in the UK, there is a real need for high-quality comparative research studies to inform practice.

Effects of an integrative warm-up method on the range of motion, core stability, and quality of squat performance of young adults

Introduction

This research aims to determine the effects of an integrative warm-up method on the range of motion in joints of the lower extremities, the strength of the stabilizer trunk muscles, and the quality of the basic movement patterns in older adolescents.

Methods

The study sample consisted of 88 male students (age 20.1 ± 0.5). They were randomly divided into four groups: one control group (CG) (n = 17; 180.8 ± 7.9 cm; 82.3 ± 8.3 kg) and three experimental groups (EG): EG1 (n = 23; 180.9 ± 7.0 cm; 78.5 ± 9.5 kg), EG2 (n = 31; 182.2 cm ± 7.3 cm; 79.5 ± 11.5 kg), and EG3 (n = 17; 183.3 ± 4.9 cm; 77.5 ± 11.8 kg). The participants were subjected to a 6-week experimental treatment: EG1 once, EG2 twice, and EG3 three times a week. The experimental treatment consisted of four sub-phases representing the integrative warm-up Method: 1) Inhibition (self-myofascial release using a foam roller); 2) Lengthening (Static stretching in a maximum range of motion position); 3) Activation (Positional isometrics muscle activation of the trunk and gluteus); 4) Integration (Integrated all the previous phases into one complex movement pattern). Based on the covariance analysis (ANCOVA), statistically significant treatment effects were observed and positive changes were determined in all experimental groups.

Results

The differences between groups were observed in the following variables: Overhead Squat Assessment (p = 0.000; η p 2 = 0.318 ), range of motion of left hip flexion (p = 0.000; η p 2 = 0.371 ), range of motion of right hip flexion (p = 0.000; η p 2 = 0.051 ) and range of motion of right hip extension (p = 0.051; η p 2 = 0.088 ), Double Leg Lowering Test (F = 2.411; p = 0.014; η p 2 = 0.014 ) and range of combined motion (plantar and dorsiflexion) of left ankle joint (p = 0.000; η p 2 = 0.299 ). There was no significant difference in the Plank Test (F = 1.007; p = 1.007; η p 2 = 0.035 ), range of combined motion (plantar and dorsiflexion) of right ankle joint (p = 0.088; η p 2 = 0.170 ) and range of motion of left hip extension (p = 0.158; η p 2 = 0.060 ). The participants of CG statistically significantly differed from EG1, EG2, and EG3 in the squat performance after the applied treatment.

Discussion

The effect of the treatment was the occurrence of a transformational processes in almost all measured variables. It can be concluded that the integrative method is effective and applicable in practice for both young adults and recreational athletes.

Scapular motion during shoulder joint extension movement

A few reports on scapular motion during shoulder joint extension exist. Understanding the normal motion of shoulder joint extension may be useful in evaluating and treating patients with diminished or minimal shoulder joint extension. Therefore, this study aimed to identify scapular motion during shoulder joint extension movement in a sitting position. Shoulder joint extension movement in the sitting position were measured in 22 healthy adults (age, 25.8 ± 2.7 years). Shoulder joint extension, scapular upward rotation, anterior tilt, external rotation angles, and the acromion position were investigated using a three-dimensional motion analyzer. The difference from each value of 10° to 50° shoulder joint extension to each value of 0° shoulder joint extension were checked. The results were compared using multiple comparison method. In most participants, the scapula tilted posteriorly up to 30° of the shoulder joint extension and anteriorly after 30°. Scapular upward and external rotation continued to increase with shoulder extension. Furthermore, the acromion was displaced upward and backward. Thus, scapular posterior tilt is necessary for shoulder joint extension during the initial movement, followed by anterior tilt. The acromion may have been displaced posteriorly because of clavicular retraction, causing the scapula to tilt posteriorly. After 30° of shoulder joint extension, the scapular anterior tilt may have prevailed over the scapular posterior tilt.

The Efficacy of Muscle Energy and Mulligan Mobilization Techniques for the Upper Extremities and Posture after Breast Cancer Surgery with Axillary Dissection: A Randomized Controlled Trial

Background: Breast cancer surgeries affect the upper extremities and posture. This study aimed to examine the efficacy of muscle energy and Mulligan mobilization techniques on the upper extremities and posture after breast cancer surgery with axillary dissection. Methods: A total of 90 female participants who had undergone breast cancer surgery with axillary dissection were recruited and randomly assigned to three groups. Group A received a combination of the Mulligan and muscle energy techniques, while Groups B and C received either the Mulligan or muscle energy techniques for six weeks, respectively. The study measured the shoulders' range of motion, posture, and upper-extremity disabilities. Outcome measurements were taken at three different time points: baseline, post-intervention, and at eight-week follow-up. Results: All the interventions significantly improved the study outcomes. The combination of the Mulligan and muscle energy techniques was significantly better than a single intervention. Mulligan mobilization was superior to the muscle energy techniques in terms of improving the shoulders' range of motion and disability. The interventions showed a significant effect pre-post-treatment and pre-follow-up but not post-follow-up. Conclusions: The Mulligan mobilization and muscle energy techniques have been found beneficial in improving the postural changes and shoulder outcomes after breast cancer surgery with axillary dissection. The superior effectiveness of the combined interventions points out the importance of integrating multiple therapeutic approaches for optimal outcomes. Regular examination and long-term follow-up assessment are important for studying the effect of rehabilitation interventions in people after the late stages of breast surgery.

Defining the glenohumeral range of motion required for overhead shoulder mobility: an observational study

Background

Recovery of overhead mobility after shoulder surgery is time-consuming and important for patient satisfaction. Overhead stretching and mobilization of the scapulothoracic and glenohumeral (GH) joints are common treatment interventions. The isolated GH range of motion (ROM) of flexion, abduction, and external rotation required to move above 120° of global shoulder flexion in the clinical setting remains unclear. This study clarified the GH ROM needed for overhead mobility.

Methods

The timely development of shoulder ROM in patients after shoulder surgery was analyzed. Passive global shoulder flexion, GH flexion, abduction, and external rotation ROM were measured using goniometry and visually at 2-week intervals starting 6-week postsurgery until the end of treatment. Receiver operating characteristic curves were used to identify the GH ROM cutoff values allowing overhead mobility.

Results

A total of 21 patients (mean age 49 years; 76% men) after rotator cuff repair (71%), Latarjet shoulder stabilization (19%), and arthroscopic biceps tenotomy (10%) were included. The ROM cutoff value that accurately allowed overhead mobility was 83° for GH flexion and abduction with the area under the curve (AUC) ranging from 0.90 to 0.93 (p < 0.001). The cutoff value for GH external rotation was 53% of the amount of movement on the opposite side (AUC 0.87, p < 0.001).

Conclusions

Global shoulder flexion above 120° needs almost full GH flexion and abduction to be executable. External rotation ROM seems less important as long as it reaches over 53% of the opposite side.

Glenohumeral versus subacromial steroid injections for impingement syndrome with mild stiffness: a randomized controlled trial

BACKGROUND

The subacromial (SA) space is a commonly used injection site for treatment of impingement syndrome. For shoulder stiffness, glenohumeral (GH) injections are commonly performed. However, in cases of impingement syndrome with mild shoulder stiffness, the optimal site of steroid injection has yet to be identified.

METHODS

This prospective, randomized study compared the short-term outcomes of ultrasound-guided GH and SA steroid injections in patients who were diagnosed with impingement syndrome and mild stiffness. Each group comprised 24 patients who received either a GH or SA injection of 40 mg of triamcinolone. Range of motion and clinical scores were assessed before and 3, 7, and 13 weeks after the injection.

RESULTS

GH and SA injections significantly improved the range of motion and clinical scores after 13 weeks of follow-up. Notably, targeting the GH joint resulted in an earlier gain of forward elevation, external rotation, and internal rotation in 3 weeks (P<0.001, P=0.012, and P=0.002, respectively) and of internal rotation and a Constant-Murley score in 7 weeks (P<0.001 and P=0.046). Subsequent measurements were similar between the groups and showed a steady improvement in all ranges of motion and clinical scores.

CONCLUSIONS

GH injections may be more favorable than SA injections for treatment of impingement syndrome with mild stiffness, especially in improving the range of motion in the early period. However, the procedures showed similar outcomes after 3 months. Level of evidence: I.

Outcomes of primary Latarjet vs. revision Latarjet after prior surgery for anterior shoulder instability: a systematic review and meta-analysis

BACKGROUND

Latarjet has become an increasingly popular treatment option for recurrent anterior shoulder instability. With the reported complication rates for primary Latarjet surgery, there are concerns about the complications of Latarjet as a revision surgery. It remains unclear if poor results after previous surgical management can be improved with revision Latarjet as well as with primary Latarjet. The aim of this systematic review and meta-analysis is to compare the outcomes of primary Latarjet and revision Latarjet for the treatment of anterior shoulder instability.

METHODS

A systematic search was performed on 3 databases for studies that compared primary Latarjet with revision Latarjet used after failed arthroscopic stabilization or failed free bone block procedures. From the included studies, demographic data, clinical outcome scores, range of motion measurements, and postoperative complications were obtained.

RESULTS

A total of 11 studies were included for data analysis. Compared with the primary Latarjet cohort, revision Latarjet cohorts had a higher infection rate (1.2% vs. 2.6%; RR 0.46, P = .039). The primary Latarjet group showed a greater rate of return to sport (89.7% vs. 80.5%; RR 1.12, P = .41) and less subjective feeling of instability (12.6% vs. 20.9%; RR 0.60, P = .085) compared with the revision Latarjet group; however, this was not statistically significant. There were no significant differences in complication rates, reoperation, recurrence, and range of motion between primary Latarjet and revision Latarjet groups. Clinical outcome scores such as visual analog scale and Rowe scores were not significantly different between the cohorts.

CONCLUSION

Based on the current evidence, primary Latarjet presents reduced infection rates but similar clinical outcome measures, overall complication, and range of motion measurements than revision Latarjet performed after failed prior operative treatment.

Clinical outcomes and temporal changes in the range of motion following reverse total shoulder arthroplasty

BACKGROUND

Reverse total shoulder arthroplasty is a definitive solution for the treatment of massive rotator cuff tear and shoulder pseudoparalysis since it can improve shoulder function, especially in elderly individuals. For many elderly individuals, the concern is when they can return to their daily lives after surgery. This study aimed to clarify the characteristics of temporal postoperative values following reverse total shoulder arthroplasty and investigate the factors that affect clinical outcomes.

METHODS

This study included 52 patients (mean 79.2 years, range 70-87 years) who underwent primary reverse total shoulder arthroplasty for shoulder pseudoparalysis at a single institution by a single surgeon using the same implant between October 2014 and June 2019. We divided 52 patient into the following groups (1) female (n = 34)vs. male (n = 18) patients; (2) with (n = 19) vs. without (n = 33) arthritic changes in glenohumeral joints (Hamada grade 2, 3 vs. 4, 5); (3) with (n = 23) vs. without (n = 29) subscapularis tendon repair; and investigated the temporal changes in the range of motion (flexion, abduction, external rotation, and internal rotation) and American Shoulder and Elbow Surgeons scores.

RESULTS

Significant differences were observed in postoperative shoulder flexion (P = .046) and abduction (P = .049) between the female and male groups. The male patients were able to obtain quick functional recovery. However, no significant differences were observed in postoperative American Shoulder and Elbow Surgeons scores, and the shoulder range of motion between patients with Hamada grade 2, 3 and 4, 5, and between the subscapularis repair and no repair groups.

CONCLUSION

The factor that affected the final and temporal values of range of motion after reverse total shoulder arthroplasty was sex, rather than the arthritic changes in glenohumeral joint and the treatment of the subscapularis tendon.

Clinical effectiveness of superior capsular reconstruction using Teflon felt graft in the elderly for pain relief: a comparison using tensor fascia lata graft

Background

The graft material generally used in superior capsular reconstruction (SCR) may be a human dermal allograft or an autologous tensor fascia lata (TFL) graft. According to a previous biomechanical study, a dermal graft (3 mm) was found to be insufficient and a thicker and stiffer graft was required. However, graft-site mobility should be considered when harvesting TFL, especially in the elderly. We have used Teflon felt as a graft material for SCR in the elderly for pain relief. This study aimed to compare the pain-relieving effects and clinical outcomes between Teflon felt and TFL graft.

Methods

This study included 39 patients (Teflon felt group: 19 patients, TFL group: 20 patients) who underwent SCR with a minimum of 2-year follow-up. Patients with painful irreparable rotator cuff tears but with shoulder elevation (abduction or flexion) of at least 130° were included in the study. Shoulder range of motion, acromiohumeral distance, and the numerical rating scale were evaluated preoperatively and 2 years postoperatively.

Results

There were no significant differences between the Teflon felt and TFL groups in terms of shoulder elevation (151 ± 33° vs. 164 ± 15°, P = .57), acromiohumeral distance (8.3 ± 2.2 mm vs. 7.5 ± 2.5 mm, P = .14), and numerical rating scale (1.0 ± 1.2 vs. 0.9 ± 0.8, P = .93).

Conclusion

SCR with Teflon graft provided pain relief equivalent to TFL graft. It may be an effective treatment option in elderly patients for irreparable rotator cuff tears with respect to pain relief.

Functional outcomes of reverse total shoulder arthroplasty in Boileau class 1 and class 2 proximal humeral fracture sequelae: A meta-analysis and systematic review

Background

Reverse total shoulder arthroplasty (RTSA) is an increasingly popular salvage treatment option for proximal humeral fracture (PHF) sequelae. This meta-analysis aimed to conduct a pooled analysis of functional outcomes of RTSA in PHF sequelae, with subgroup analysis comparing between intracapsular (Class 1) and extracapsular (Class 2) PHF sequelae.

Methods

A multi-database search (PubMed, OVID, EMBASE) was performed according to PRISMA guidelines on 27th July 2020. Data from all published literature meeting inclusion criteria were extracted and analysed.

Findings

Eleven studies were included, comprising 359 shoulders (167 Class 1 and 192 Class 2). The mean age was 68.2 years, and the mean time between injury and surgery was 49 months, (1-516 months). Constant score and forward flexion improved by 31.8 (95%CI: 30.5-33.1, p < 0.001) and 60o (95%CI: 58o-62o, p < 0.001) respectively between pre-operative and post-operative values for both groups. Constant scores were better in Class 1 patients (MD = 3.60, 95%CI: 1.0-6.2, p < 0.001) pre-operatively and post-operatively (MD = 7.4, 95%CI: 5.8-9.0, p < 0.001). Forward flexion was significantly better in Class 1 patients (MD = 13o, 95%CI: 7o-17o, p < 0.001) pre-operatively, but was slightly better in Class 2 patients post-operatively (MD = 7o, 95%CI: 4o-10o, p < 0.001). Overall complication rate was 16.8%.

Conclusion

Salvage RTSA is effective for PHF sequelae, with multiple factors contributing to the high complication rate.

Design and Analysis of an Upper Limb Rehabilitation Robot Based on Multimodal Control

To address the rehabilitation needs of upper limb hemiplegic patients in various stages of recovery, streamline the workload of rehabilitation professionals, and provide data visualization, our research team designed a six-degree-of-freedom upper limb exoskeleton rehabilitation robot inspired by the human upper limb's structure. We also developed an eight-channel synchronized signal acquisition system for capturing surface electromyography (sEMG) signals and elbow joint angle data. Utilizing Solidworks, we modeled the robot with a focus on modularity, and conducted structural and kinematic analyses. To predict the elbow joint angles, we employed a back propagation neural network (BPNN). We introduced three training modes: a PID control, bilateral control, and active control, each tailored to different phases of the rehabilitation process. Our experimental results demonstrated a strong linear regression relationship between the predicted reference values and the actual elbow joint angles, with an R-squared value of 94.41% and an average error of four degrees. Furthermore, these results validated the increased stability of our model and addressed issues related to the size and single-mode limitations of upper limb rehabilitation robots. This work lays the theoretical foundation for future model enhancements and further research in the field of rehabilitation.

FUNCTIONAL ASSESSMENT OF THE SHOULDER IN JIU-JITSU BLACK BELT ATHLETES

OBJECTIVE

To assess the epidemiological profile of Jiu-Jitsu black belt athletes, including the prevalence of pain and shoulder function.

METHODS

Cross-sectional study carried out with Jiu-Jitsu athletes from 2014 to 2016. The studied variables were: sex, age, dominant limb, weight, height, profession, time of Jiu-Jitsu practice, weekly training hours, other practiced sports, comorbidities, injuries and previous surgeries, medications and habits. For the functional assessment of the shoulder, the ASES Score was used.

RESULTS

53 male athletes were evaluated. There was a prevalence of alcohol consumption (60.4%) and supplement use (32.1%). The practice of other sports included weight training (49.1%) and other martial arts (17%). There was a prevalence of knee (66.0%) and shoulder (52.8%) injuries and, in some cases, the need for surgical procedures. There was a prevalence of shoulder pain (73.6%) and more than half of the athletes (52.9%) had minimal or moderate limitation of shoulder function.

CONCLUSION

Jiu-jitsu black belt athletes often have a history of injuries, with the shoulder being the second most affected body part. In more than half of the athletes, there was a prevalence of shoulder pain and functional limitation, according to the ASES Score. Level of evidence III, Retrospective comparative study.

Study on proximal humerus evaluation of effective treatment (SPHEER) - what is the effect of rehabilitation compliance on clinical outcomes of proximal humerus fractures

INTRODUCTION

Proximal humeral fractures (PHFs) are 3rd commonest fragility fractures and cause significant functional impairment. This paper sought to determine impact of rehabilitation compliance on the clinical outcomes for non-surgically managed PHFs, while ascertaining reasons for non-compliance which can be addressed to improve compliance.

METHODS

Prospective cohort study of patients undergoing non-surgical treatment for PHFs from August 2017 to April 2020 in a tertiary trauma centre was performed. Data was collected via questionnaire: patient demographic data, PHF injury details, clinical outcome measures, therapist-reported (Sport Injury Rehabilitation Adherence Scale [SIRAS]) and patient-reported (subjective compliance, frequency of exercise) rehabilitation compliance measures. Data was analysed using multiple linear regression model to account for confounding variables.

RESULTS

107 participants attended physical therapy follow-up for mean 137.8 days. 6-week SIRAS strongly predicted 3-month Constant score (p = 0.023; 95%CI = 0.265,3.423), OSS (p = 0.038; 95%CI = 0.049,1.634), flexion ROM (p < 0.001; 95%CI = 2.872,8.982), extension ROM (p = 0.035; 95%CI = 0.097,2.614), abduction ROM (p = 0.002;95%CI = 1.995,8.466) and achievement of functional active ROM at 3-months (p = 0.049; 95%CI = 1.001,1.638). Pain was the top reason impairing rehabilitation compliance from therapist (43.9% at 6-weeks and 20.6% at 3-months) and patient-perspective (33.6% at 6-weeks, 24.3% at 3-months). Author-developed patient-reported compliance measures had good correlation with validated SIRAS score (subjective compliance: p < 0.001 frequency of exercise: p = 0.001).

CONCLUSION

Rehabilitation compliance predicts short-term clinical outcomes up to 3-months and potentially 1-year outcomes. Pain control should be optimised to maximise rehabilitation compliance and improve PHF outcomes. There is lack of consensus definition for rehabilitation compliance measures; patient-reported measures used have good correlation to existing validated measures and could serve as a steppingstone for further research.

LEVEL OF EVIDENCE

II, cohort study.

Comparison of Outcomes After Reverse Total Shoulder Arthroplasty in Patients With Proximal Humerus Fractures Versus Rotator Cuff Arthropathy

INTRODUCTION

Indications for reverse total shoulder arthroplasty (rTSA) has expanded to encompass complex proximal humerus fractures (PHFs) in recent years. The purpose of this study was to report and assess whether PHF patients treated with rTSA could achieve similar functional outcomes and short-term survivorship to patients who underwent rTSA for rotator cuff arthropathy (RTCA).

METHODS

All consecutive patients with a preoperative diagnosis of PHF or RTCA, 18 years or older, treated with rTSA at a single academic institution between 2018 and 2020 with a minimum 2-year follow-up were retrospectively reviewed. Primary outcomes were survivorship defined as revision surgery or implant failure analyzed using the Kaplan-Meier survival curve, and functional outcomes, which included Quick Disabilities of the Arm, Shoulder, and Hand, and range of motion (ROM) were compared at multiple follow-up time points up to 2 years. Secondary outcomes were patient demographics, comorbidities, surgical data, length of hospital stay, and discharge disposition.

RESULTS

A total of 48 patients were included: 21 patients (44%) were diagnosed with PHF and 27 patients (56%) had RTCA. The Kaplan-Meier survival rate estimates at 3 years were 90.5% in the PHF group and 85.2% in the RTCA group. No differences in revision surgery rates between the two groups (P = 0.68) or survivorship (P = 0.63) were found. ROM was significantly lower at subsequent follow-up time points in multiple planes (P < 0.05). A greater proportion of patients in the PHF group received cement for humeral implant fixation compared with the RTCA group (48% versus 7%, P = 0.002). The mean length of hospital stay was longer in PHF patients compared with RTCA patients (2.9 ± 3.8 days versus 1.6 ± 1.8 days, P = 0.13), and a significantly lower proportion of PHF patients were discharged home (67% versus 96%, P = 0.015).

CONCLUSION

The rTSA implant survivorship at 3 years for both PHF and RTCA patients show comparable results. At the 2-year follow-up, RTCA patients treated with rTSA were found to have better ROM compared with PHF patients.

Discordance between patient-reported and objectively measured internal rotation after reverse shoulder arthroplasty

BACKGROUND

Patient satisfaction after reverse shoulder arthroplasty (RSA) partly relies on restoring functional internal rotation (IR). Although postoperative assessment of IR includes objective appraisal by the surgeon and subjective report from the patient, these evaluations may not vary together uniformly. We assessed the relationship between objective, surgeon-reported assessments of IR and subjective, patient-reported ability to perform IR-related activities of daily living (IRADLs).

METHODS

Our institutional shoulder arthroplasty database was queried for patients undergoing primary RSA with a medialized-glenoid lateralized-humerus design between 2007-2019 and minimum 2-year follow-up. Patients who were wheelchair bound or had a preoperative diagnosis of infection, fracture, and tumor were excluded. Objective IR was measured to the highest vertebral level reached with the thumb. Subjective IR was reported based on patients' rating (normal, slightly difficult, very difficult, or unable) of their ability to perform 4 IRADLs (tuck in shirt with hand behind back, wash back or fasten bra, personal hygiene, and remove object from back pocket). Objective IR was assessed preoperatively and at latest follow-up and reported as median and interquartile ranges.

RESULTS

A total of 443 patients were included (52% female) at a mean follow-up of 4.4 ± 2.3 years. Objective IR improved pre- to postoperatively from L4-L5 (buttocks to L1-L3) to L1-L3 (L4-L5 to T8-T12) (P < .001). Preoperatively reported IRADLs of "very difficult" or "unable" significantly decreased postoperatively for all IRADLs (P ≤ .004) except those unable to perform personal hygiene (3.2% vs. 1.8%, P > .99). The proportions of patients who improved, maintained, and lost objective and subjective IR was similar between IRADLs; 14%-20% improved objective IR but lost or maintained subjective IR and 19%-21% lost or maintained the same objective IR but improved subjective IR depending on the specific IRADL assessed. When ability to perform IRADLs improved postoperatively, objective IR also increased (P < .001). In contrast, when subjective IRADLs worsened postoperatively, objective IR did not significantly worsen for 2 of 4 IRADLs assessed. When examining patients who reported no change in ability to perform IRADLs pre- vs. postoperatively, statistically significant increases in objective IR were found for 3 of 4 IRADLs assessed.

CONCLUSIONS

Objective improvement in IR parallels improvements in subjective functional gains uniformly. However, in patients with worse or equivalent IR, the ability to perform IRADLs postoperatively does not uniformly correlate with objective IR. When attempting to elucidate how surgeons can ensure patients will have sufficient IR after RSA, future investigations may need to use patient-reported ability to perform IRADLs as the primary outcome measure rather than objective measures of IR.

Improved outcomes of older patients with acute and displaced proximal humerus fractures treated with window bone ingrowth fracture-specific stem reverse shoulder arthroplasty

BACKGROUND

The optimal treatment of displaced proximal humerus fractures (PHFs) in the older people population remains controversial. Reverse shoulder arthroplasty (RSA) is a popular surgical treatment option that provides improved and reproducible results. However, the relevance of fracture-specific stem designs for RSA to improve tuberosity consolidation and shoulder function remains debatable.

METHODS

This study included all patients 70 years or older with acute and displaced PHFs primarily treated with RSA at a single institution in Portugal, between January 2010 and December 2019 who participated in a minimum follow-up of 2 years.

RESULTS

A total of 112 patients (15 men and 97 women) with a median clinical follow-up of 52 months were included. The mean age at the time of fracture was 78.6 years. All fractures were classified as Neer types 3 and 4 (n = 50 and n = 62, respectively). A window bone ingrowth fracture-specific stem was used for 86 patients, and a conventional humeral stem was used for 26 patients. Regarding the tuberosity fixation technique, 76 tuberosities were attached using technique A (according to Boileau's principles), 36 tuberosities were attached using technique B (not following Boileau's principles) and 11cases were classified as technique C (if fixation was not possible). The overall survival rate during the 2-year follow-up was 88.2%; however, this decreased to 79% at 5 years. Only three patients had complications (two infections and one dislocation) requiring revision surgery. In the multivariable analysis, the tuberosity fixation technique (P = 0.012) and tuberosity anatomical consolidation (P < 0.001) were associated with improved Constant scores (median Constant Score 62.67 (technique A), 55.32 (technique B), 49.70 (technique C). Fracture-specific humeral implants (P = 0.051), the tuberosity fixation technique (P = 0.041), tuberosity anatomical consolidation (P < 0.001), and dementia influenced the achievement of functional mobility (P = 0.014). Tuberosity anatomic consolidation was positively associated with bone ingrowth fracture-specific humeral implants (P < 0.01) and a strong tuberosity fixation technique (P < 0.01).

CONCLUSION

RSA is used for complex and displaced fractures of the proximal humerus in older patients. Dementia was negatively correlated with functional outcomes. A window bone ingrowth fracture-specific stem combined with strong tuberosity fixation can yield better clinical and radiological results.

LEVEL OF EVIDENCE

Level II; prospective comparative study; treatment study.

Cut-off values of internal rotation in the glenohumeral joint for functional tasks in children with brachial plexus birth injury

The aim of this study was to determine the cut-off values of the range of internal rotation motion in the isolated glenohumeral joint that is required for functional tasks in children with an upper root injury of the brachial plexus. Internal rotation motion was measured using a universal goniometer in 97 participants. The Mallet Hand to Spine and Mallet Hand to Belly tasks were assessed as functional tasks that require internal rotation of the shoulder. For the Hand to Spine task, 41° passive and 30° active internal rotation were necessary to reach the S1 level. For the Hand to Belly task, 42° passive and 29° active internal rotation were required to place the palm on the belly without wrist flexion. Of our participants, 97% could touch the belly with or without wrist flexion, but 28% could not reach S1 in the Hand to Spine task. The results of this study show the necessary amount of internal rotation of the shoulder that should be considered in treatment strategies.Level of evidence: III.

Effect of different loads on the shoulder in abduction postures: a finite element analysis

Load can change the mechanical environment of dynamic and static stable structures of the shoulder joint, increase the risk of tissue damage and affect the stability of the shoulder joint, but its biomechanical mechanism is still unclear. Therefore, a finite element model of the shoulder joint was constructed to analyze the mechanical index changes of shoulder joint abduction under different loads. The stress of the articular side on the supraspinatus tendon was higher than that of the capsular side, with a maximum difference of 43% due to the increased load. For the deltoid muscle and glenohumeral ligaments, increases in stress and strain were obvious in the middle and posterior deltoid muscles and inferior glenohumeral ligaments. The above results indicate that load increases the stress difference between the articular side and the capsular side on the supraspinatus tendon and increases the mechanical indices of the middle and posterior deltoid muscles, as well as the inferior glenohumeral ligament. The increased stress and strain in these specific sites can lead to tissue injury and affect the stability of the shoulder joint.