Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study

Level of diagnostic agreement in musculoskeletal shoulder diagnosis between remote and face-to-face consultations: A retrospective service evaluation

Background and Aims

To determine the level of diagnostic agreement between remote and face-to-face consultation in assessing shoulder complaints.

Methods

A retrospective service evaluation with three groups of patient data; those assessed only face-to-face (group 1), remotely then face-to-face (group 2), remotely only (group 3). Patient data were extracted from 6 secondary care shoulder Advanced Physiotherapy Practitioner's (APPs) records, covering six sites. Three-hundred-and-fifty-nine sets of patient data were included in the final evaluation. The main outcome measure was the percentage of agreement between diagnosis at initial and follow-up consultation, when assessed by APPs across the three groups. A Pearson χ 2 test was used to assess the relationship between the method of consultation and the level of diagnostic agreement. Diagnoses were categorized as either the same, similar, or different by an independent APP. Secondary outcome measures investigated whether age or the length of time between appointments had any effect in determining the level of diagnostic concordance.

Results

There was exact agreement of 77.05% and 85.52% for groups 1 and 3, respectively, compared with 34.93% for patient data in group 2. Similar clinical impressions across both initial and follow-up were seen 16.39% of the time in group 1, 7.24% of the time in group 3, and 36.99% in group 2. Lastly, the percentage of times a diagnosis was changed between initial and review appointments occurred in only 6.56% of group 1 contacts, 7.24% of group 3 contacts, but 28.08% of the time in group 2.

Conclusion

There was a large mismatch in the diagnosis of musculoskeletal shoulder complaints, when patients are initially assessed remotely and then followed-up in-person. This has implications for the future provision of shoulder assessment in physiotherapy.

Which preoperative factors influence the patient's short-term subjective assessment after rotator cuff repair?

INTRODUCTION

To highlight the preoperative risk factors that influence postoperative patient satisfaction following Rotator Cuff Repair (RCR) and to determine whether this satisfaction was correlated with tendon healing.

HYPOTHESIS

Preoperative factors influence patient satisfaction, assessed by SSV (Subjective Shoulder Value) postoperatively, with a correlation with tendon healing.

METHODS

With a mean age of 60.6 years (40-72), 102 patients with arthroscopic RCR were included retrospectively. The preoperative SSV score was less than or equal to 50%. There was clinical and radiological follow-up with an ultrasound evaluation of tendon healing 6 months postoperatively. We divided the patients into 2 groups using a postoperative SSV of 85% as the cut-off; 55 patients in the first group (SSV>85%); and 47 patients in the second group (SSV<85%).

RESULTS

In multivariate analysis, Preoperative risk factors for poor postoperative SSV after RCR were: tobacco use [-8.41 (-13.64; -3.17) p=0.002], fatty infiltration [-3.65 (-6.24 -1.06) p=0.006] and workers compensation [-19.15 (-24.04; -14.27) p<0.001]. When patients were not in workers compensation, the lower their SSV score before surgery, the higher their postoperative SSV score. For patients in workers compensation, the higher the SSV preoperatively, the less elevated was SSV postoperatively. The Sugaya ultrasound classification did not influence the SSV score (p=0.15) CONCLUSIONS: Smoking, fatty infiltration and patients in workers compensation are factors of poorer subjective results evaluated by the SSV score. Tendon healing did not influence the SSV score and patient satisfaction.

LEVEL OF EVIDENCE

IV, cohort study.

Age, Tear Size, Extent of Retraction, and Fatty Infiltration Associated With a High Chance of a Similar Rotator Cuff Tear in the Contralateral Shoulder Regardless of Symptoms in Patients Undergoing Cuff Repair in the Index Shoulder

PURPOSE

To investigate the prevalence of a contralateral rotator cuff tear (RCT) in patients with a symptomatic RCT requiring repair and to determine whether findings from magnetic resonance imaging (MRI) of the affected shoulder can predict the presence of a contralateral tear.

METHODS

Patients with atraumatic RCTs who had undergone arthroscopic repair between March 2019 and February 2021 were reviewed in this study. MRI of both shoulder joints was performed to evaluate the bilaterality of RCT. Demographic factors and MRI findings of index shoulders were assessed using logistic regression analysis to reveal any correlations with the presence of RCT in the contralateral shoulder.

RESULTS

A total of 428 patients were enrolled in this study. When the affected shoulders had a posterosuperior rotator cuff (PSRC) or subscapularis tear including either an isolated or combined tear, 63.6% and 67.8% had the same tears on the contralateral side, respectively. A contralateral-side tear was found in 74.6% (185/248) of symptomatic cases and 44.8% (65/145) of asymptomatic cases, which represents a significant difference (P < .001). Logistic regression analysis revealed that age ≥67.5 years, tear size ≥17 mm, Goutallier grade ≥1.5, and Patte grade ≥1.5 were found to be indicative of potential contralateral PSRC tears. By contrast, the presence of a subscapularis tear in the affected shoulder was the only significant risk factor in predicting a potential subscapularis tear in the contralateral shoulder.

CONCLUSIONS

Among patients with a symptomatic RCT requiring arthroscopic repair, 63.6% with a PSRC tear and 67.8% with a subscapularis tear in the affected shoulder were found to have a similar tear in the contralateral shoulder regardless of symptoms. Age, tear size, extent of retraction, fatty infiltration of PSRC tears, and the presence of subscapularis tears were identified as factors predictive of tears on the contralateral side.

LEVEL OF EVIDENCE

IV, case series.

Proximal humerus fractures and shoulder dislocations: Prevalence of concomitant rotator cuff tear

Background: Proximal humerus fractures and shoulder dislocations are relatively common. However, an associated rotator cuff tear is often missed with these injuries. The objective of this study was to assess the prevalence of a concomitant rotator cuff tear associated with common shoulder injuries. Methods: A cross-sectional epidemiological study of three patient populations: Group 1. Proximal Humerus Fractures; Group 2. Shoulder Dislocations; Group 3. Proximal Humerus Fracture-Dislocations. All patients within these three groups presented to and underwent subsequent management of their shoulder injury at a trauma unit. Management included both non-operative and operative intervention. Patients were evaluated for associated rotator cuff tears. Results: This study included a total of 196 patients: Group 1 = 146 Proximal Humerus Fractures; Group 2 = 37 Shoulder Dislocations; Group 3 = 13 Proximal Humerus Fracture-Dislocations. Of the 196 patients in total, 23 (11.7%) sustained a concomitant rotator cuff tear. The highest number of tears was found in Group 1 ( n = 14). However, the highest percentage prevalence of tears was in Group 2 (18.9%). There was noted to be a higher prevalence of rotator cuff tears with increasing age. Twenty-two (95.7%) rotator cuff tears were detected in patients over 50 years of age. The vast majority of rotator cuff tears were detected by ultrasound (78.3%) as opposed to magnetic resonance imaging (21.7%). The majority of tears were full-thickness (60.9%). Of the 23 patients with a concomitant rotator cuff tear, 17 involved a single tendon (73.9%) and supraspinatus was most common (69.6%). Conclusions: A concomitant rotator cuff tear in association with a proximal humerus fracture, shoulder dislocation or proximal humerus fracture-dislocation is relatively common. The overall rotator cuff tear prevalence in this study was 11.9%. Rotator cuff tears are more likely to occur in patients over 50 years old and those sustaining a shoulder dislocation.

Prevalence of rotator cuff tendon tears and symptoms in a Chingford general population cohort, and the resultant impact on UK health services: a cross-sectional observational study

OBJECTIVES

To define the population prevalence of rotator cuff tears and test their association with pain and function loss; determine if severity symptom correlates with tear stage severity, and quantify the impact of symptomatic rotator cuff tears on primary healthcare services in a general population cohort of women.

DESIGN

Cross-sectional observational study.

PARTICIPANTS

Individuals were part of the Chingford 1000 Women cohort, a 20-year-old longitudinal population study comprising 1003 women aged between 64 and 87, and representative of the population of the UK.

MAIN OUTCOME MEASURES

Rotator cuff pathology prevalence on ultrasound, shoulder symptoms using the Oxford Shoulder Score and resultant number of general practitioner (GP) consultations.

RESULTS

The population prevalence of full-thickness tears was 22.2%, which increased with age (p=0.004) and whether it was the dominant arm (Relative Risk 1.64, OR 1.58, 95% CI 1.07 to 2.33, p=0.021).Although 48.4% of full-thickness tears were asymptomatic, there was an association between rotator cuff tears and patient-reported symptoms. Individuals with at least one full-thickness tear were 1.97 times more likely than those with bilateral normal tendons (OR 3.53, 95% CI 2.00 to 5.61, p<0.001) to have symptoms. Severity of symptoms was not related to the severity of the pathology until tears are >2.5 cm (p=0.009).In the cohort, 8.9% had seen their GP with shoulder pain and a full-thickness rotator cuff tear, 18.8% with shoulder pain and an abnormality and 29.3% with shoulder pain.

CONCLUSION

Rotator cuff tears are common, and primary care services are heavily impacted. As 50% of tears remain asymptomatic, future research may investigate the cause of pain and whether different treatment modalities, aside from addressing the pathology, need further investigation.

MRI findings in atraumatic shoulder pain-patterns of disease correlated with age and gender

BACKGROUND

The rotator cuff is a group of muscles and tendons which support the shoulder joint. Rotator cuff disease is a frequent cause of morbidity in adulthood.

AIMS

The aims of his study are to determine the prevalence and patterns of rotator cuff derangement in symptomatic patients using MRI and to attempt to correlate identified patterns of disease with age and gender METHODS: Five hundred ninety-seven patients attending for MRI of the shoulder with atraumatic shoulder pain were included for study. Patients' age and gender was recorded. Record was made of the presence or absence of rotator cuff derangement and of degenerative change in the AC and glenohumeral joints. Correlation was made between age and gender.

RESULTS

There were 358 males (60%) and 239 females (40%) with a mean age of 49.4 ± 17.1 years. Subacromial bursitis was identified in 517 patients. A normal supraspinatus tendon was identified in 219 patients and supraspinatus full thickness tearing was identified in 102 patients. A normal AC joint was identified in 267 patients while degenerative AC joint changes were identified in 370 patients. A significant correlation was identified between age and rotator cuff derangement (p < .001) and between age and AC joint derangement (p < .001). No significant difference was identified between gender and patterns of cuff derangement CONCLUSION: The extent of rotator cuff and AC joint derangement increases with ageing. Impingement appears to trigger a cascade of events in sequence, from isolated subacromial bursitis through to supraspinatus tendon tearing. Patterns of rotator cuff derangement are similar in men and women.

Supraspinatus tendon thickness and subacromial impingement characteristics in younger and older adults

Background

Subacromial impingement (SAI) may be a cause of age-related rotator cuff abnormalities; therefore, the purpose of this study was to compare SAI characteristics between younger and older adults. In addition to the fact that thickened supraspinatus tendon (SST) indicates tendon abnormalities, SAI characteristics have been recognized as follows: greater SST thickness, reduced acromiohumeral distance (AHD), greater reduction of AHD (∆AHD) with arm elevation, and a higher percentage of SST within AHD (i.e., occupation ratio: OcAHD). Furthermore, we investigated the relationships between SST thickness and AHD, as well as SST thickness and ∆AHD to clarify the effect of SAI on rotator cuff abnormalities.

Methods

Healthy younger (n = 18, 21–24-year-old) and older (n = 27, 45–80-year-old) adults without any shoulder symptoms participated in this study. We measured their SST thickness and AHD at rest and at arm elevation (30° and 60°) in the scapular plane using ultrasound, and calculated ∆AHD as the relative change expressed as a percentage of the baseline. OcAHD was expressed as the ratio of SST thickness at rest to AHD at rest and in elevated positions.

Results

The older subjects had approximately one mm thicker SST (P = 0.003, 95% Confidence interval [CI] = 0.410 to 1.895) and approximately 1.0 to 1.3 mm greater AHD than the younger subjects (P = 0.011, 95%CI = 0.284 to 2.068 at rest; P = 0.037, 95%CI = 0.082 to 2.609 for 30° of arm elevation; P = 0.032, 95%CI = 0.120 to 2.458 for 60° of arm elevation). However, there were no differences in ΔAHD and OcAHD between the groups.

Conclusion

This study demonstrated that, compared with the younger subjects, the older subjects showed thicker supraspinatus tendon but no other SAI characteristics including decreases in AHD and increases in OcAHD. Thus, this study suggests that older subjects showed age-related SST abnormalities without SAI, although the magnitude of the differences in SST thickness is notably small and the clinical significance of this difference is unclear.

The significance of urgent ultrasound scan for shoulder dislocation in patients above the age of 40: A prospective British Elbow and Shoulder Society pathway implementation study

BACKGROUND

The highlight of the British Elbow and Shoulder Society pathway for the management of traumatic anterior shoulder instability is early imaging in patients aged over 40 years to assess rotator cuff integrity and early repair, if indicated to optimise function. The senior author set up a protocol in our institute to streamline the diagnostic process for this cohort of patients. This was a retrospective analysis from a prospectively collected database to highlight the importance of early specialist imaging.

METHODS

Our protocol is to perform urgent ultrasound scans for all suitable patients above 40 years after first-time traumatic shoulder dislocation. Demographics, associated injuries, ultrasound scan results, operations and functional outcomes were collated.

RESULTS

One year following the introduction of our protocol, 40 patients with a mean age of 67 (range, 42-89; SD = 13.1) had ultrasound. The incidence of full-thickness rotator cuff tears was 57.5% (n = 23). Eleven patients with confirmed full-thickness rotator cuff tears underwent surgery. The mean age of surgical patients was significantly younger than the non-surgical group (p = 0.004).

DISCUSSION

The use of early diagnostic imaging demonstrated a high incidence of full-thickness rotator cuff tears in this cohort of patients. This allowed early surgical repair to optimise function.

Ultrasonographic findings of shoulders in individuals with spinal cord injury

Objective: To investigate shoulder ultrasonography findings in spinal cord injury (SCI) and identify factors associated with ultrasongraphic abnormalities.Design: A cross-sectional descriptive studySetting: Srinagarind hospital, ThailandParticipants: Spinal cord injury patients who attended the Srinagarind Hospital rehabilitation department.Outcome Measures: Baseline characteristics, physical examination, Physical Examination of the Shoulder Scale (PESS), and the ultrasonography of both shoulders of SCI patients were prospectively evaluated.Results: Ninety-one SCI patients were enrolled in this study, (56 with paraplegia and 35 with quadriplegia). Most patients in both groups had incomplete SCI. Wheelchairs were the most commonly used assistive devices in both groups. The top three ultrasonographic abnormalities in patients with quadriplegia were unilateral subdeltoid-subacromion bursitis (65.7%), unilateral supraspinatus tendinosis (45.7%), and unilateral biceps tendon effusion (37.2%). The most common abnormalities in those with paraplegia were unilateral subdeltoid-subacromion bursitis (64.3%), unilateral biceps tendon effusion (55.4%), and unilateral supraspinatus tendinosis (53.6%).Conclusions: Abnormal shoulder US findings were prevalent in individuals with SCI. The most common ultrasonographic abnormalities in patient with SCI was unilateral subdeltoid-subacromion bursitis.

Rotator cuff integrity and shoulder function after intra-medullary humerus nailing

INTRODUCTION

Antegrade percutaneous intra-medullary nailing (IMN) has a poor reputation in the treatment of humerus fractures. The aim of the present study was to assess rotator cuff integrity and shoulder function after IMN in humerus fracture.

HYPOTHESIS

Third-generation humeral nails (straight, small diameter, with locked screws) conserve rotator cuff tendon integrity and avoid the shoulder stiffness and pain incurred by 1st generation (large diameter, without self-blocking screw) and 2nd generation nails (curved, penetrating the supraspinatus insertion on the greater tuberosity).

METHODS

Forty patients (26 female, 14 male; mean age, 60 years (range, 20-89 years)) with displaced humeral fracture (23 proximal humerus, 17 humeral shaft) underwent IMN using a 3rd generation nail (34 Aequalis™ (Tornier-Wright), 6 MultiLoc™ (Depuy-Synthes)). Mean clinical, radiologic and ultrasound follow-up was 8 months (range, 6-18 months); 22 patients agreed to postoperative CT scan.

RESULTS

There were no revision surgeries for rotator cuff repair or secondary bone displacement. Mean Adjusted Constant Score (ACS) was 93±22% and the Subjective Shoulder Value (SSV) 77±18%. Elevation was 140±36°, external rotation 48±22° and internal rotation was to L3. Ultrasound found: 5 supraspinatus tendon lesions (12.5%) (2 full and 3 deep partial tears) without functional impact (ACS) 91% without vs. 107% with tear; (p=0.12); 2 of the deep partial tears involved excessively lateral and high nail positioning. Eight patients (20%) had painful tendinopathy of the long head of the biceps (LHB) tendon associated with significantly impaired functional scores (ACS 65% vs. 100%; p<0.001); and 4 cases of technical error: 3 of anterior LHB screwing in the groove, and 1 of LHB irritation due to an excessively long posterior screw.

CONCLUSION

Supraspinatus tendon lesions following IMN with a 3^rd-generation humeral nail were rare (12.5%) and asymptomatic; prevalence was not higher than in the general population in the literature (16%). LHB tendinopathy was frequent (20%) and symptomatic, and due to technical error in half of the cases.

LEVEL OF EVIDENCE

IV, retrospective study.

Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain

BACKGROUND

Magnetic resonance imaging (MRI) is commonly used to diagnose structural abnormalities in the shoulder. However, subsequent findings may not be the source of symptoms. The aim of this study was to determine comparative MRI findings across both shoulders of individuals with unilateral shoulder symptoms.

MATERIALS AND METHODS

We prospectively evaluated 123 individuals from the community who had self-reported unilateral shoulder pain with no signs of adhesive capsulitis, no substantial range-of-motion deficit, no history of upper-limb fractures, no repeated shoulder dislocations, and no neck-related pain. Images in the coronal, sagittal, and axial planes with T1, T2, and proton density sequences were generated and independently and randomly interpreted by 2 examiners: a board-certified, fellowship-trained orthopedic shoulder surgeon and a musculoskeletal radiologist. Absolute and relative frequencies for each MRI finding were calculated and compared between symptomatic and asymptomatic shoulders. Agreement between the shoulder surgeon and the radiologist was also determined.

RESULTS

Abnormal MRI findings were highly prevalent in both shoulders. Only the frequencies of full-thickness tears in the supraspinatus tendon and glenohumeral osteoarthritis were higher (approximately 10%) in the symptomatic shoulder according to the surgeon's findings. Agreement between the musculoskeletal radiologist and shoulder surgeon ranged from slight to moderate (0.00-0.51).

CONCLUSION

Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. Clinicians should be aware of the common anatomic findings on MRI when considering diagnostic and treatment planning.

Trends Associated with Open Versus Arthroscopic Rotator Cuff Repair

BACKGROUND

Rotator cuff (RTC) repair is performed using open/mini-open or arthroscopic procedures, and the use of arthroscopic techniques is increasing. The extent to which surgery has transitioned from open to arthroscopic techniques has yet to be elucidated.

QUESTIONS/PURPOSES

The purpose of this study was to evaluate trends in open and arthroscopic rotator cuff repair in the USA and describe tendencies in treatment across gender, age, and geographic region. We hypothesized that surgeons would be more likely to perform arthroscopic rotator cuff repair, with similar trends across the USA.

METHODS

A retrospective review of a comprehensive national insurance database (Humana) was performed using the PearlDiver software for all patients who underwent RTC repair between January 2007 and June 2015. Patients were identified by Current Procedural Terminology (CPT) codes. χ ² tests evaluated the proportion of arthroscopic surgeries by gender and geographic region; logistic regression analysis assessed differences from 2007 to 2015.

RESULTS

In the study period, 54,740 patients underwent RTC repair (68% arthroscopic, 52% male), with the highest frequency of RTC repair in patients between 65 and 69 years old. The proportion of open RTC repair increased with increasing patient age, with no significant difference between men and women. The proportion of arthroscopic RTC surgeries increased from 56.9% in 2007 to 75.1% in 2015. The overall trend was 188% increase in total RTC repairs. Arthroscopic repair was more frequent than open repair in all US regions, with the highest proportion in the South.

CONCLUSION

Arthroscopic RTC surgery predominates and continues to rise. With increasing patient age, there was an increase in the proportion of open repair. The majority of RTC repairs were performed in patients between 65 and 69 years of age.

Asymptomatic Rotator Cuff Tears

Asymptomatic rotator cuff tears (RCTs) are prevalent in the general population; they are positively associated with age and are common in the contralateral shoulder of individuals who are being treated for shoulder pain or a symptomatic RCT. Asymptomatic RCTs are likely to become symptomatic over time, corresponding with decreased patient-reported function, strength, and range of motion. Previous studies have largely reported inconsistent findings regarding patient-reported outcomes, strength, range of motion, and kinematics in individuals with asymptomatic RCTs. Future research would benefit from characterizing any functional alteration that is associated with asymptomatic rotator cuff pathology, including determining whether such alterations are detrimental or compensatory and understanding the mechanism by which an asymptomatic RCT becomes symptomatic.

A prospective study of patients with shoulder pain and Mechanical Diagnosis and Therapy (MDT)

Objectives: A prospective observational cohort study was conducted to (1) determine the prevalence of Mechanical Diagnosis and Therapy (MDT) syndromes for patients with shoulder impairments and (2) report the interaction between MDT classification and clinical outcomes, including pain intensity and disability, at discharge.Methods: Clinical outcome measures were completed at intake and discharge by 115 patients. A two-way mixed model analysis of variance with subsequent pairwise comparisons was done to examine differences in clinical outcomes between the following MDT classifications: Shoulder Derangement, Shoulder Dysfunction, and Other.Results: The primary findings were that (1) 44.3 (35.3, 53.4), 40.0 (31.0, 48.9), and 15.6 (9.0, 22.3) percent of patients' conditions were classified as Shoulder Derangement, Shoulder Dysfunction, and Other, respectively, (2) all groups managed via MDT methods made clinically significant improvements in disability and pain intensity at discharge, (3) a statistically significant difference in pain intensity at discharge was observed between the Shoulder Derangement and the Shoulder Dysfunction classifications (p = 0.01), and (4) patients with the Shoulder Derangement classification were discharged, on average, 35.3 days earlier than the Shoulder Dysfunction classification and 28.3 days earlier than the Other classification.Discussion: This study confirms previous reports that the Shoulder Derangement and Shoulder Dysfunction classifications are common and represent distinct clinical trajectories when assessed and managed via MDT methods.

Rotator cable and rotator interval: anatomy, biomechanics and clinical importance

The rotator cable and rotator interval are among the most recent topics of interest in current shoulder literature. Most of the research has been published in the last two decades and our understanding about the importance of these anatomical structures has improved with biomechanical studies, which changed the pre- and intra-operative approaches of shoulder surgeons to rotator cuff tears in symptomatic patients.

The rotator cable is a thick fibrous bundle that carries the applied forces to the rotator cuff like a ‘suspension bridge’. Tears including this weight-bearing bridge result in more symptoms. On the other hand, the rotator interval is more like a protective cover consisting of multiple layers of ligaments and the capsule rather than a single anatomical formation like the rotator cable.

Advances in our knowledge about the rotator interval demonstrate that even basic anatomical structures often have greater importance than we may have understood. Misdiagnosis of these two important structures may lead to persistent symptoms.

Furthermore, some distinct rotator cuff tear patterns can be associated with concomitant rotator interval injuries because of the anatomical proximity of these two anatomical regions. We summarize these two important structures from the aspect of anatomy, biomechanics, radiology and clinical importance in a review of the literature.

Cite this article: EFORT Open Rev 2019;4:56-62. DOI: 10.1302/2058-5241.4.170071.

Rehabilitation of symptomatic atraumatic degenerative rotator cuff tears: A clinical commentary on assessment and management

STUDY DESIGN

Clinical Commentary.

INTRODUCTION

Atraumatic rotator cuff (RC) disease, is one of the most common cause of shoulder pain, which encompasses a continuum from tendinopathy to full thickness cuff tears. Extrinsic, intrinsic and environmental factors have been implicated in the pathophysiology of this disorder, affecting the clinical presentation of symptoms including pain and irritability. Successful rehabilitation of symptomatic atraumatic degenerative rotator cuff (SADRC) tears must address the underlying mechanisms causing dysfunction and correct modifiable factors.

PURPOSE OF THE STUDY

The purpose of this paper is to review the shoulder complex anatomy, introduce atraumatic degenerative RC pathology, differentiate between symptomatic and asymptomatic degenerative RC tears, propose an assessment and introduce the Rotator Cuff Protocol 1 (RCP1) designed by the clinical reasoning of one of the lead authors (LW) as a rehabilitation management approach for those clients who present with SADRC tears.

METHODS/RESULTS/DISCUSSION

N/A for clinical commentary.

CONCLUSIONS

The ability to identify SADRC tears should consider shoulder anatomy, extrinsic, intrinsic and environmental factors, and the consideration for the natural history of atraumatic partial and full thickness tears in the general population. A thorough clinical history and examination, which includes shoulder symptom modification tests, allows the examiner to determine at what phase the patient may start their exercise program. The RCP1 is a program that has been used clinically by many therapists and clients over the years and research is underway to test this protocol in atraumatic rotator cuff disease including SADRC tears.

LEVEL OF EVIDENCE

5.

Patient self-assessed shoulder comfort and function and active motion are not closely related to surgically documented rotator cuff tear integrity

BACKGROUND

The rationale for rotator cuff repair surgery is that better integrity of the cuff should be associated with better comfort and function. However, in patients with cuff disease, there is not good evidence that the degree of rotator cuff integrity is closely associated with the shoulder's comfort, function, or active motion. The goal of this study was to explore these relationships in shoulders with surgically documented cuff disease.

METHODS

In 55 shoulders having surgery for cuff-related symptoms, we correlated the preoperative Simple Shoulder Test score with the objectively measured preoperative active shoulder motion and with the integrity of the cuff observed at surgery.

RESULTS

The 16 shoulders with tendinosis or partial-thickness tears had an average Simple Shoulder Test score of 3.7 ± 3.3, active abduction of 111° ± 38°, and active flexion of 115° ± 36°. The corresponding values were 3.6 ± 2.8, 94° ± 47°, and 94° ± 52° for the 22 full-thickness supraspinatus tears and 3.9 ± 2.7, 89° ± 39°, and 100° ± 39° for the 17 supraspinatus and infraspinatus tears.

CONCLUSION

In this study, surgically observed cuff integrity was not strongly associated with the shoulder's comfort or function. Whereas surgeons often seek to improve the integrity of the rotator cuff, the management of patients with rotator cuff disorders needs to be informed by a better understanding of the factors other than cuff integrity that influence the comfort and functioning of shoulders with cuff disease.

Dry needling in a manual physiotherapy and therapeutic exercise protocol for patients with chronic mechanical shoulder pain of unspecific origin: a protocol for a randomized control trial

Background

Shoulder pain of musculoskeletal origin is the main cause of upper limb pain of non-traumatic origin. Despite being one of the most common reasons for consultation, there is no established protocol for treatment due to the complexity of its etiology. However, it has been shown that the presence of myofascial trigger points on the shoulder muscles is a common condition associated with patients suffering from shoulder pain. This protocol has been created which describes the design of a randomized controlled trial to evaluate the effectiveness of the inclusion of dry needling (DN) within a protocol of manual physiotherapy and therapeutic exercise in the treatment of chronic shoulder pain of unspecific origin.

Methods

Thirty-six participants aged 18–65 years will be recruited having mechanical chronic shoulder pain on unspecific origin and meeting the inclusion criteria. These will be randomized to one of two interventions, (i) DN, manual physiotherapy and therapeutic exercise or (ii) sham DN, manual physiotherapy and therapeutic exercise. The protocol will cover 6 weeks of treatment, with a 6-month follow-up. Our main outcome measure will be the Visual Analogue Scale for pain.

Discussion

This is the first study to combine the use of DN, manual physiotherapy and an exercise program with a 6-month follow-up, thus becoming a new contribution to the treatment of chronic shoulder pain, while new lines of research may be established to help determine the effects of DN on chronic shoulder pain and the frequency and proper dosage.

Trial registrations

International Standard Randomized Controlled Trial Number Register: ISRCTN30604244 (http://www.controlled-trials.com) 29 June 2016.

Ultrasonography of the shoulder: asymptomatic findings from working-age women in the general population

[Purpose] The aim of this study was to estimate the prevalence of abnormal shoulder ultrasonographic findings in a sample of asymptomatic women. [Subjects and Methods] A secondary analysis of a cross-sectional study was performed. We recruited 305 women (aged 18–56 years). All the subjects had a structured interview screening for self-reported symptoms and underwent a shoulder ultrasonographic examination, in which both shoulders were examined. The radiologist was blinded to the clinical history of the participants. All detectable shoulder abnormalities were collected. [Results] Of the subjects, 228 (74.75%) were asymptomatic at both shoulders, and 456 asymptomatic shoulders were analyzed. Lack of uniformity (supraspinatus, infraspinatus, subscapularis, and biceps brachii long head) was found in 28 shoulders (6.14%), 19 (4.17%) on the dominant side and 9 (1.97%) on the non-dominant side. Tendinosis (supraspinatus, infraspinatus, subscapularis, and biceps brachii long head) was found in 19 shoulders (5.32%), 12 (2.63%) on the dominant side and 7 (1.53%) on the non-dominant side. Calcification and other abnormal findings were reported. [Conclusion] The most common abnormalities were calcifications within the rotator-cuff tendons and humeral head geodes; other degenerative findings were less common.

Application of the McKenzie system of Mechanical Diagnosis and Therapy (MDT) in patients with shoulder pain; a prospective longitudinal study

Objectives

The primary objective was to determine if the pain and function response to the McKenzie system of Mechanical Diagnosis and Therapy (MDT) differs by MDT classification category at two and four weeks following the start of MDT treatment for shoulder complaints. The secondary objective was to describe the frequency of discharge over time by MDT classification.

Methods

International, MDT-trained study collaborators recruited 93 patients attending physiotherapy for rehabilitation of a shoulder problem. The Numeric Pain Rating Scale (NPRS) and the Upper Extremity Functional Index (UEFI) were collected at the initial assessment and two and four weeks after treatment commenced. A two-way mixed model analysis of variance with planned pairwise comparisons was performed to identify where the differences between MDT classification groups actually existed.

Results

The Derangement and Spinal classifications had significantly lower NPRS scores than the Dysfunction group at week 2 and week 4 (p < 0.05). The Derangement and Spinal classifications had significantly higher UEFI scores than the Dysfunction group at week 2 and week 4 (p < 0.05). The frequency of discharge at week 2 was 37% for both Derangement and Spinal classifications, with no discharges for the Dysfunction classification at this time point. The frequency of discharge at week 4 was 83, 82 and 15% for the Derangement, Spinal and Dysfunction classifications, respectively.

Discussion

Classifying patients with shoulder pain using the MDT system can impact treatment outcomes and the frequency of discharge. When MDT-trained clinicians are allowed to match the intervention to a specific MDT classification, the outcome is aligned with the response expectation of the classification.Level of Evidence: 2b.

Ultrasound-detected pathologies cluster into groups with different clinical outcomes: data from 3000 community referrals for shoulder pain

Background

Ultrasound is increasingly used to evaluate shoulder pain, but the benefits of this are unclear. In this study, we examined whether ultrasound-defined pathologies have implications for clinical outcomes.

Methods

We extracted reported pathologies from 3000 ultrasound scans of people with shoulder pain referred from primary care. In latent class analysis (LCA), we identified whether individual pathologies clustered in groups. Optimal group number was determined by the minimum Bayesian information criterion. A questionnaire was sent to all patients scanned over a 12-month period (n = 2322). Data collected included demographics, treatments received, current pain and function. The relationship between pathology-defined groups and clinical outcomes was examined.

Results

LCA revealed four groups: (1) bursitis with limited inflammation elsewhere (n = 1280), (2) bursitis with extensive inflammation (n = 595), (3) rotator cuff tears (n = 558) and (4) limited pathology (n = 567). A total of 777 subjects (33%) completed questionnaires. The median (IQR) duration post-ultrasound scan was 25 (22–29) months. Subsequent injections were most common in groups 1 and 2 (groups 1–4 76%, 67%, 48% and 61%, respectively); surgery was most common in group 3 (groups 1–4 23%, 21%, 28% and 16%, respectively). Shoulder Pain and Disability Index scores were highest in group 3 (median 48 and 30, respectively) and lowest in group 4 (median 32 and 9, respectively). Patients in group 4 who had surgery reported poor outcomes.

Conclusions

In a community-based population, we identified clusters of pathologies on the basis of ultrasound. Our retrospective data suggest that these groups have different treatment pathways and outcomes. This requires replication in a prospective study to determine the value of a pathology-based classification in people with shoulder pain.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1235-y) contains supplementary material, which is available to authorized users.

Prevalence of asymptomatic rotator cuff tear and their related factors in the Korean population

BACKGROUND

No information is available about asymptomatic rotator cuff tears (RCTs) in the Korean population. This study evaluated the prevalence of rotator cuff tears without symptoms and their related risk factors.

MATERIALS AND METHODS

The study included 486 volunteers (70.4% female; mean age, 53.1; range, 20-82 years) without any shoulder symptom complaints. Background data, medical history, clinical self-assessment, and physical examination were recorded. An ultrasonographic examination was conducted to identify rotator cuff pathology, but only full-thickness RCTs (FTRCTs) were included for the statistical analysis.

RESULTS

FTRCTs were found in 23 subjects (4.7%) but only in those aged ≥49 years. Subjects aged 50-59, 60-69, and ≥70 years of age had FTRCT prevalence rates of 3.5%, 13.3%, and 11.1%, respectively. The prevalence of FTRCTs was higher in subjects with diabetes (P = .042) and a smoking history (P= .002), but no differences were noted for the presence of thyroid disease (P = .051). Almost half of those who had FTRCTs had some pain and limited daily activity that was not bothersome. After excluding these subjects from the analysis, the prevalence of asymptomatic FTRCTs decreased to 2.3%.

CONCLUSIONS

The prevalence of asymptomatic FTRCTs was lower than expected. Half of asymptomatic FTRCTs were not actually symptom free after the clinical and physical assessments. The risk factors for a FTRCT were age, diabetes, and smoking.

Diabetes mellitus increases the risk of rotator cuff tear repair surgery: A population-based cohort study

BACKGROUND

Rotator cuff tears are the most common cause of shoulder disability in people older than 50years, and surgical intervention is usually required for restoring functioning. However, in patients undergoing rotator cuff repair surgery, patients with DM had poorer functional outcomes than those without DM, and hence, DM is one of the possible risks factor for rotator cut off tear. The aim of this population-based study was to investigate the relationship between DM and the risk of rotator cuff tear in patients receiving rotator cuff repair surgery.

METHODS

In this retrospective longitudinal population-based 7-year cohort study, we investigated the risk of rotator cuff repair surgery in patients with DM. We performed a case-control matched analysis by using data from the Taiwan Longitudinal Health Insurance Database 2005. Patients were enrolled on the basis of the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes for DM between January 1, 2004, and December 31, 2007. The prevalence and the adjusted hazard ratios (HRs) of a rotator cuff repair surgery in patients with and without DM were estimated according to the Cox proportional hazard regression analysis using the frailty model.

RESULTS

The DM and non-DM cohorts comprised 58,652 patients with DM and 117,304 (1:2) patients without DM after matching for age and sex. The incidence of rotator cuff repair surgery was 41 per 100,000 and 26 per 100,000 person-years in the DM and non-DM cohorts, respectively. The HR of rotator cuff repair surgery during the follow-up period was 1.56 (95% confidence interval [CI] 1.25-1.93, p<0.001) for patients with DM. After adjustment for covariates, the adjusted HR of rotator cuff repair surgery was 1.33 (95% CI, 1.05-1.68, p<0.001) in the DM cohort.

CONCLUSION

DM is an independent risk factor for rotator cuff tear repair surgery.

Fractures of the greater tuberosity of the humerus: a study of associated rotator cuff injury and atrophy

BACKGROUND

This is a retrospective prognostic study on soft tissue injury following isolated greater tuberosity (GT) fractures of the proximal humerus with respect to the relationship between rotator cuff tears and GT displacement.

METHODS

Forty-three patients with isolated GT fractures were recruited and evaluated with a standardized interview and physical examination, quality of life and shoulder function questionnaires (Western Ontario Rotator Cuff Index, SF-12 Version 2, Constant, Quick-Disabilities of the Arm, Shoulder and Hand, Visual Analogue Scale), standard shoulder radiographs and an ultrasound. The main outcome measurements were: incidence of rotator cuff tears and atrophy, biceps pathology and sub-acromial impingement; superior displacement of the GT fragment; and questionnaire scores.

RESULTS

Mean age was 57 years (31 years to 90 years) with a follow-up of 2.4 years (0.8 years to 6.8 years). In total, 16% had a full rotator cuff tear and 57% showed subacromial impingement on ultrasound. Full rotator cuff tears and supraspinatus fatty atrophy significantly correlated with decreased function and abduction strength. Significant atrophy (>50%) of the supraspinatus and infraspinatus, without a rotator cuff tear, was correlated with the worst function in the presence of a residual displacement of the greater tuberosity at the last-follow-up (7 mm).

CONCLUSIONS

Residual displacement, full rotator cuff tear and muscle atrophy are associated with the worst outcomes. Soft tissue imaging could benefit patients with an unfavourable outcome after a GT fracture to treat soft tissue injury.

Rapamycin Attenuates Age-associated Changes in Tibialis Anterior Tendon Viscoelastic Properties

Rapamycin extends mouse life span, but the extent to which rapamycin prevents aging-associated changes in specific tissues remains unclear. Stiffness increases and collagen turnover decreases in mouse tendon with aging; thus, our aim was to determine the effect of long-term rapamycin treatment on the mechanical and structural properties of tendons from old mice. Tendons were harvested from female UM-HET3 mice maintained on a standard chow diet for 4 (adult) or 22 (old) months or fed chow containing polymer-encapsulated rapamycin (eRAPA) from 9 to 22 months of age (old RAPA). Stiffness was twofold higher for tendons of old compared with adult mice, but in old RAPA mice, tendon stiffness was maintained at a value not different from that of adults. Additionally, expression of collagen decreased, expression of matrix metalloproteinase-8 increased, and total hydroxyproline content trended toward decreased levels in tendons of old eRAPA-fed mice compared with controls. Finally, age-associated calcification of Achilles tendons and accompanying elevations in expression of chondrocyte and osteoblast markers were all lower in old eRAPA-fed mice. These results suggest that long-term administration of rapamycin alters the molecular pathways responsible for aging of tendon extracellular matrix, resulting in tissue that is structurally and mechanically similar to tendons in adult mice.

Utility of features of the patient's history in the diagnosis of atraumatic shoulder pain: a systematic review

BACKGROUND

Whereas physical examination tests for shoulder disorders have numeric values that describe the utility of the test and its effect on the probability of having a diagnosis, this information is lacking for elements of the history. The purpose of this study was to conduct a systematic review of the literature to determine numeric data (sensitivity, specificity, predictive values, and likelihood or odds ratios) for elements of the history with regard to diagnoses in patients with chronic atraumatic shoulder pain.

METHODS

We performed a systematic review to extract information from the existing literature regarding the numeric utility of different features of the patient history as they pertain to chronic atraumatic shoulder pain. Data sources were MEDLINE through PubMed (1946-January 2012) and EMBASE through Ovid (1980-January 2012).

RESULTS

Twenty-one studies met inclusion criteria. A diagnosis of rotator cuff tear was more likely with a history of hypercholesterolemia, having a relative with rotator cuff disease, excessive lifting, above-shoulder work, hand-held vibration work, or age older than 60 years. Acromioclavicular arthritis was more likely in weightlifters. Glenohumeral arthritis was more likely if the patient has a history of prior dislocation, age >75 years, or a diagnosis of knee osteoarthritis. Adhesive capsulitis was more likely with a history of diabetes or thyroid disorder. Posterior labral tear was more likely in football players.

CONCLUSIONS

The numeric values for the utility of these history features will help establish numeric probabilities for diagnoses in patients with shoulder pain.

Critical review on the socio-economic impact of tendinopathy

There are currently no studies that determine the total burden that tendinopathy places on patients and society. A systematic search was conducted to understand the impact of tendinopathy. It demonstrated that the current prevalence is underestimated, particularly in active populations, such as athletes and workers. Search results demonstrate that due to the high prevalence, impact on patients' daily lives and the economic impact due to work-loss, treatments are significantly higher than currently observed. A well-accepted definition by medical professionals and the public will improve documentation and increase awareness, in order to better tackle the disease burden.

Patients With Impingement Syndrome With and Without Rotator Cuff Tears Do Well 20 Years After Arthroscopic Subacromial Decompression

PURPOSE

To present the long-term outcome of arthroscopic subacromial decompression (ASD) for patients with impingement syndrome with or without rotator cuff tears as well as with or without calcific tendinitis in a follow-up of 20 years.

METHODS

We included 95 patients after a mean follow-up of 19.9 (19.5 to 20.5) years. All patients underwent ASD, including acromioplasty, resection of the coracoacromial ligament, and coplaning without cuff repair. The Constant score was used to assess the functioning of the shoulder. In addition, we defined a combined failure end point of a poor Constant score and revision surgery.

RESULTS

Revision surgery was performed in14.7% of the patients. The combined end point showed successful results in 78.8% of all cases. All patients with isolated impingement syndrome achieved successful results. Those with partial-thickness tears had successful outcomes in 90.9% of all cases, and patients with full-thickness tears had successful outcomes in 70.6% of all cases. The tendinitis calcarea group showed the poorest results, with a 65.2% success rate.

CONCLUSIONS

Our long-term results show that patients with impingement syndrome who received ASD, including acromioplasty, resection of the coracoacromial ligament, and coplaning do well 20 years after the index surgery. ASD without cuff repair even appears to be a safe, efficacious, and sustainable procedure for patients with partial rotator cuff tears.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

A prospective evaluation of survivorship of asymptomatic degenerative rotator cuff tears

BACKGROUND

The purpose of this prospective study was to report the long-term risks of rotator cuff tear enlargement and symptom progression associated with degenerative asymptomatic tears.

METHODS

Subjects with an asymptomatic rotator cuff tear in one shoulder and pain due to rotator cuff disease in the contralateral shoulder enrolled as part of a prospective longitudinal study. Two hundred and twenty-four subjects (118 initial full-thickness tears, fifty-six initial partial-thickness tears, and fifty controls) were followed for a median of 5.1 years. Validated functional shoulder scores were calculated (visual analog pain scale, American Shoulder and Elbow Surgeons [ASES], and simple shoulder test [SST] scores). Subjects were followed annually with shoulder ultrasonography and clinical evaluations.

RESULTS

Tear enlargement was seen in 49% of the shoulders, and the median time to enlargement was 2.8 years. The occurrence of tear-enlargement events was influenced by the severity of the final tear type, with enlargement of 61% of the full-thickness tears, 44% of the partial-thickness tears, and 14% of the controls (p < 0.05). Subject age and sex were not related to tear enlargement. One hundred subjects (46%) developed new pain. The final tear type was associated with a greater risk of pain development, with the new pain developing in 28% of the controls, 46% of the shoulders with a partial-thickness tear, and 50% of those with a full-thickness tear (p < 0.05). The presence of tear enlargement was associated with the onset of new pain (p < 0.05). Progressive degenerative changes of the supraspinatus muscle were associated with tear enlargement, with supraspinatus muscle degeneration increasing in 4% of the shoulders with a stable tear compared with 30% of the shoulders with tear enlargement (p < 0.05). Nine percent of the shoulders with a stable tear showed increased infraspinatus muscle degeneration compared with 28% of those in which the tear had enlarged (p = 0.07).

CONCLUSIONS

This study demonstrates the progressive nature of degenerative rotator cuff disease. The risk of tear enlargement and progression of muscle degeneration is greater for shoulders with a full-thickness tear, and tear enlargement is associated with a greater risk of pain development across all tear types.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Ultrasound imaging for tailored treatment of patients with acute shoulder pain

PURPOSE

The objective of this study was to assess the frequencies of ultrasound findings in patients with acute rotator cuff disorders in family medicine.

METHODS

In a prospective observational study, 129 patients aged 18 to 65 years with acute shoulder pain in whom the family physician suspected rotator cuff disease underwent ultrasound imaging.

RESULTS

Rotator cuff disease was present in 81% of the patients, and 50% of them had multiple disorders. Calcific tendonitis was the most frequently diagnosed specific disorder. An age of 40 years or older was most strongly related to rotator cuff disease.

CONCLUSIONS

Ultrasound imaging enables family physicians to rationalize treatment in nearly all patients who are aged 40 years and older with acute shoulder pain.

A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age

Hypothesis and background: Abnormalities of the rotator cuff are more common with age, but the exact prevalence of abnormalities and the extent to which the presence of an abnormality is associated with symptoms are topics of debate. Our aim was to review the published literature to establish the prevalence of abnormalities of the rotator cuff and to determine if the prevalence of abnormalities increases with older age in 10-year intervals. In addition, we assessed prevalence in 4 separate groups: (1) asymptomatic patients, (2) general population, (3) symptomatic patients, and (4) patients after shoulder dislocation.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library up to February 24, 2014, and included studies reporting rotator cuff abnormalities by age. Thirty studies including 6112 shoulders met our criteria. We pooled the individual patient data and calculated proportions of patients with and without abnormalities per decade (range, younger than 20 years to 80 years and older).

RESULTS

Overall prevalence of abnormalities increased with age, from 9.7% (29 of 299) in patients aged 20 years and younger to 62% (166 of 268) in patients aged 80 years and older (P < .001) (odds ratio, 15; 95% confidence interval, 9.6-24; P < .001). There was a similar increasing prevalence of abnormalities regardless of symptoms or shoulder dislocation.

DISCUSSION AND CONCLUSION

The prevalence of rotator cuff abnormalities in asymptomatic people is high enough for degeneration of the rotator cuff to be considered a common aspect of normal human aging and to make it difficult to determine when an abnormality is new (e.g., after a dislocation) or is the cause of symptoms.

Inter-examiner reliability of diplomats in the mechanical diagnosis and therapy system in assessing patients with shoulder pain

OBJECTIVE

To investigate the inter-examiner reliability of Mechanical Diagnosis and Therapy (MDT)-trained diplomats in classifying patients with shoulder disorders. The MDT system has demonstrated acceptable reliability when used in patients with spinal disorders; however, little is known about its utility when used for appendicular conditions.

METHODS

Fifty-four clinical scenarios were created by a group of 11 MDT diploma holders based on their clinical experience with patients with shoulder pain. The vignettes were made anonymous, and their clinical diagnoses sections were left blank. The vignettes were sent to a second group of six international McKenzie Institute diploma holders who were asked to classify each vignette according to the MDT categories for upper extremity. Inter-examiner agreement was evaluated with kappa statistics.

RESULTS

There was 'very good' agreement among the six MDT diplomats for classifying the McKenzie syndromes in patients with shoulder pain (kappa = 0.90, SE = 0.018). The raw overall level of multi-rater agreement among the six clinicians in classifying the vignettes was 96%. After accounting for the actual MDT category for each vignette, kappa and the raw overall level of agreement decreased negligibly (0.89 and 95%, respectively).

DISCUSSION

Using clinical vignettes, the McKenzie system of MDT has very good reliability in classifying patients with shoulder pain. As an alternative, future reliability studies could use real patients instead of written vignettes.

Prevalence of and risk factors for asymptomatic rotator cuff tears in postmenopausal women

OBJECTIVE

Rotator cuff tendon tears increase with age, but no study has specifically addressed prevalence changes in women from premenopause to postmenopause. The aims of this study were to evaluate the prevalence of rotator cuff asymptomatic tears in postmenopausal women and to study their relationship with anthropometric and metabolic measures.

METHODS

Premenopausal and postmenopausal women who were free from shoulder pain/functional impairment were enrolled. Body mass index (BMI), fasting glucose, triglycerides, total cholesterol, and high-density lipoprotein (HDL) cholesterol were evaluated. Both shoulders were examined by ultrasound imaging. For the purposes of this study, only full-thickness tears (classified as small, large, or massive) were taken into account.

RESULTS

The prevalence of full-thickness tears (mainly localized in the supraspinatus tendon of the dominant side) was significantly higher in the postmenopausal group (8.9% vs 3.1%), with small, medium, and large tears in 60%, 20%, and 20% of cases, respectively. In women with tears, intragroup comparison showed significantly higher values for BMI and fasting glucose, and lower levels of HDL cholesterol; no difference was found for triglycerides and total cholesterol in premenopausal and postmenopausal women, respectively. On multiple logistic regression analysis, the probability of detecting a tear in both groups was positively related to high values of BMI and lower levels of HDL cholesterol.

CONCLUSIONS

The prevalence of asymptomatic full-thickness tears is increased in the postmenopausal period, and there is an association between tears and metabolic disorders. Because asymptomatic tears have a great potential to evolve into symptomatic painful shoulder, a precocious discovery of this pathology may allow the planning of preventive and therapeutic measures.

Assessment of glenohumeral subluxation in poststroke hemiplegia: comparison between ultrasound and fingerbreadth palpation methods

BACKGROUND

Glenohumeral subluxation (GHS) is a common poststroke complication. Treatment of GHS is hampered by the lack of objective, real-time clinical measurements.

OBJECTIVE

The aims of this study were: (1) to compare an ultrasound method of GHS measurement with the fingerbreadth palpation method using a receiver operating characteristic curve (ROC) and (2) to report the sensitivity and specificity of this method.

DESIGN

A prospective study was conducted.

SETTING

The study was conducted in local hospitals and day centers in the southwest of England.

PATIENTS

One hundred five patients who had one-sided weakness following a first-time stroke (51 men, 54 women; mean age=71 years, SD=11) and who gave informed consent were enrolled in the study.

MEASUREMENTS

Ultrasound measurements of acromion-greater tuberosity (AGT) distance were used for the assessment of GHS. Measurements were undertaken on both shoulders by a research physical therapist trained in shoulder ultrasound with the patient seated in a standardized position. Fingerbreadth palpation assessment of GHS was undertaken by a clinical physical therapist based at the hospital, who also visited the day centers.

RESULTS

The area under the ROC curve was 0.73 (95% confidence interval [95% CI]=0.63, 0.83), suggesting that the ultrasound method has good agreement compared with the fingerbreadth palpation method. A cutoff point of ≥0.2 cm AGT measurement difference between affected and unaffected shoulders generated a sensitivity of 68% (95% CI=51%, 75%), a specificity of 62% (95% CI=47%, 80%), a positive likelihood ratio of 1.79 (95% CI=1.1, 2.9), and a negative likelihood ratio of 0.55 (95% CI=0.4, 0.8).

LIMITATIONS

Clinical therapists involved in the routine care of patients conducted the fingerbreadth palpation method. It is likely that they were aware of the patients' subluxation status.

CONCLUSION

The ultrasound method can detect minor asymmetry (≤0.5 cm) and has the potential advantage over the fingerbreadth palpation method of identifying patients with minor subluxation.

Prevalence of rotator cuff tears in operative proximal humerus fractures

Proximal humerus fractures and rotator cuff tears have been shown to have increasing rates with advancing age, theoretically leading to significant overlap in the 2 pathologies. The goal of this study was to examine the prevalence, associated factors, and effect on treatment of rotator cuff tears in surgically treated proximal humerus fractures. A retrospective review was performed of all patients who had surgery for a proximal humerus fracture from January 2007 to June 2012 in the shoulder department of a large academic institution. Patient demographics, the presence and management of rotator cuff tears, and surgical factors were recorded. Regression analysis was performed to determine which factors were associated with rotator cuff tears. This study reviewed 349 fractures in 345 patients. Of these, 30 (8.6%) had concomitant rotator cuff tears. Those with a rotator cuff tear were older (average age, 68.7 vs 63.1 years), were more likely to have had a dislocation (40% vs 12.5%), and were more likely to have undergone subsequent arthroscopic repair or reverse total shoulder arthroplasty than those without a rotator cuff tear. Most (22 of 30) were treated with suture repair at the time of surgery, but 5 patients underwent reverse total shoulder arthroplasty based primarily on the intraoperative finding of a significant rotator cuff tear. A concomitant rotator cuff tear in association with a proximal humerus fracture is relatively common. Rotator cuff tears are associated with older patients and those with a fracture-dislocation. In rare cases, these cases may require the availability of a reverse shoulder prosthesis.

Ultrasound dimensions of the rotator cuff in young healthy adults

BACKGROUND

No studies have looked at the rotator cuff dimensions in the young healthy population using ultrasonography. Our aim is to define the ultrasound dimensions of the rotator cuff in the healthy young adult population and explore correlations with other patient characteristics.

METHODS

Thirty male and 30 female healthy volunteers (aged 18-40 years), with no shoulder problems, underwent ultrasound assessment of both shoulders by a musculoskeletal radiologist. The dimensions of the rotator cuff, deltoid, and biceps were measured in a standardized manner.

RESULTS

A total of 120 shoulders were scanned. The mean maximum width of the supraspinatus footprint was 14.9 mm in men and 13.5 mm in women (P < .001). The mean thickness of the supraspinatus tendon was 4.9 mm in women and 5.6 mm in men. The mean thickness of the subscapularis was 4.4 in men and 3.8 mm in women and for the infraspinatus was 4.9 mm in men and 4.4 mm in women. There was no correlation between height, weight, biceps, or deltoid thickness with any tendon measurements. Apart from supraspinatus tendon thickness, the difference between dominant and nondominant shoulders in the same sex was not significant for any other tendon dimensions.

CONCLUSION

This study has defined the dimensions of the rotator cuff in the young healthy adult, which has not been previously published. This is important for the documentation of normal ultrasound anatomy of the rotator cuff and also demonstrates that the asymptomatic contralateral shoulder can and should be used to estimate the expected dimensions.

Does immobilization position after arthroscopic rotator cuff repair impact work quality or comfort?

PURPOSE

The purpose of this study was to quantify subjective discomfort and decrease in working performance in patients submitted to arthroscopic rotator cuff repair.

METHODS

We enrolled 101 asymptomatic administrative employees (mean age 55). Subjects were asked to write a text using Microsoft Word and to make a table using Microsoft Excel, with and without shoulder braces which kept the right shoulder in neutral (brace A) and internal rotation (brace B). Total time needed to complete the tests and number of mistakes committed were annotated. Furthermore, a questionnaire to assess the subjective and interpersonal discomfort caused by the braces was compiled. Data were submitted to statistical analysis.

RESULTS

When any brace is worn, both times and mistakes are higher than those registered without brace (p < 0.02). Both times and mistakes are higher for brace B in comparison with brace A (p < 0.02). Subjects wearing brace B had a severe/very severe discomfort degree three times higher than that registered in subjects wearing brace A. Finally, 91 % of subjects preferred brace A to brace B.

DISCUSSION

If the choice of the brace is not supported by biological or clinical advantages, we recommend to use the brace that keeps the arm at the side, since it ensures better working performance and lower discomfort. It also received the greatest satisfaction of the respondents.

LEVEL OF EVIDENCE

IV.

Quantitative diagnostic method for biceps long head tendinitis by using ultrasound

Objective. To investigate the feasibility of grayscale quantitative diagnostic method for biceps tendinitis and determine the cut-off points of a quantitative biceps ultrasound (US) method to diagnose biceps tendinitis. Design. Prospective cross-sectional case controlled study. Setting. Outpatient rehabilitation service. Methods. A total of 336 shoulder pain patients with suspected biceps tendinitis were recruited in this prospective observational study. The grayscale pixel data of the range of interest (ROI) were obtained for both the transverse and longitudinal views of the biceps US. Results. A total of 136 patients were classified with biceps tendinitis, and 200 patients were classified as not having biceps tendinitis based on the diagnostic criteria. Based on the Youden index, the cut-off points were determined as 26.85 for the transverse view and 21.25 for the longitudinal view of the standard deviation (StdDev) of the ROI values, respectively. When the ROI evaluation of the US surpassed the cut-off point, the sensitivity was 68% and the specificity was 90% in the StdDev of the transverse view, and the sensitivity was 81% and the specificity was 73% in the StdDev of the longitudinal view to diagnose biceps tendinitis. Conclusion. For equivocal cases or inexperienced sonographers, our study provides a more objective method for diagnosing biceps tendinitis in shoulder pain patients.

Acromio-clavicular joint cyst associated with a complete rotator cuff tear - a case report

This case report describes a patient with an acromio-clavicular joint (ACJ) cyst, associated with a complete tear of the supraspinatus tendon, and the related arthropathy. Ultrasound was a suitable imaging modality to make the diagnosis, and rule out other pathologies. Full assessment of the rotator cuff must be carried out in the presence of ACJ cysts due to their common co-existence with large cuff tears. Cyst aspiration is not a suitable treatment, due to the high likelihood of recurrence. Optimal treatment requires management of the underlying rotator cuff tear.

Humeral shaft fractures treated with antegrade intramedullary nailing: what are the consequences for the rotator cuff?

PURPOSE

The purpose of this study was to investigate the clinical and sonographic impact on the rotator cuff (RC) of the use of the anterolateral approach for nailing.

METHODS

A retrospective cohort of 48 patients treated for humeral diaphyseal fractures at the University Hospital of Parma between 2007 and 2011 was analysed. Inclusion criteria were (1) acute humeral shaft fractures treated with T2-proximal humeral nail (PHN) and (2) a minimum follow-up of one year. Exclusion criteria were (1) history of proximal and metaphyseal humeral fractures, (2) pathological fractures or open fractures of the humerus, and (3) RC lesions. Clinical assessment using the Constant score, simple shoulder test and through shoulder examination tests was carried out. The sonographic study investigated the integrity of the RC.

RESULTS

Mean score on Constant's scale was 78.21 points, with most patients achieving a good result (79% obtained more than 65 points). One patient had a limited functional outcome (Constant's score of 49 points). The sonographic findings described for supraspinatus tendon were a partial ruptures of less than 30 mm in three patients and a complete tendon rupture in one case.

CONCLUSIONS

The results of this study suggest that the use of the anterolateral approach for antegrade humeral nailing ensures a good functional result with no significant clinical-sonographic impact on the rotator cuff and a satisfactory long term clinical outcome.

Morphology of large rotator cuff tears and of the rotator cable and long-term shoulder disability in conservatively treated elderly patients

OBJECTIVE

The objective of this study was to describe the morphology of the rotator cuff tendon tears and long-term shoulder disability in conservatively treated elderly patients and determine if an association exists between these factors.

METHODS

Assessment of the rotator cuff tendon tear dimensions and depth, rotator interval involvement, rotator cable morphology and location, and rotator cuff muscle status was carried out on magnetic resonance studies of 24 elderly patients treated nonoperatively for rotator cuff tendon tears. Long-term shoulder function was measured using the Western Ontario Rotator Cuff (WORC) index; Disabilities of the Shoulder, Arm, and Hand questionnaire; and the American Shoulder Elbow Self-assessment form, and a correlation between the outcome scores and morphologic magnetic resonance findings was carried out.

RESULTS

The majority of large rotator cuff tendon tears are limited to the rotator cuff crescent. Medial rotator interval involvement (isolated or in association with lateral rotator interval involvement) was significantly associated with WORC physical symptoms total (P = 0.01), WORC lifestyle total (P = 0.04), percentage of all WORC domains (P = 0.03), and American Shoulder Elbow Self-assessment total (P = 0.01), with medial rotator interval involvement associated with an inferior outcome.

CONCLUSIONS

Medial rotator interval tears are associated with long-term inferior outcome scores in conservatively treated elderly patients with large rotator cuff tendon tears.

Analysis of rotator cuff repair trends in a large private insurance population

PURPOSE

The purpose of this study was to identify current trends in open and arthroscopic surgical treatment of rotator cuff tears across sex, age, and region in the United States.

METHODS

Using the PearlDiver Patient Record Database (PearlDiver, Fort Wayne, IN), a publicly available national database of insurance records, patients who underwent rotator cuff repair from 2004 through 2009 were identified. The number of open (CPT codes 23410, 23412, 23420) and arthroscopic (CPT code 29827) rotator cuff repairs were quantified in isolation and in combination with acromioplasty (CPT codes 23415, 29826). The type of procedure, date, sex, and region of the country was identified for each patient. Trend tests (χ(2) and Cochran-Armitage) were used to determine statistical significance.

RESULTS

There were 151,866 rotator cuff repair procedures identified in the database from 2004 through 2009, which represented an incidence of 13.6 for every 1,000 patients assigned an orthopaedic International Classification of Diseases, Ninth Revision (ICD-9) or Current Procedural Terminology (CPT) code. Male patients accounted for 60% of the repairs and female patients for 40%. There were 98,174 arthroscopic cuff repairs (65%) and 53,692 open repairs (35%). The annual percentage of arthroscopic cases increased from 48.8% in 2004 to 74.3% in 2009, whereas the percentage of open cases decreased from 51.2% in 2004 to 25.7% in 2009 (P < .0001). Acromioplasty was also performed in 47.3% of cases, and the rate showed only a slight increase (from 46.6% to 47.8%) between 2004 and 2009 (P < .01). All regions of the United States showed similar surgical trends and trends for sex and age distributions.

CONCLUSIONS

Our analysis shows that the majority of rotator cuff repairs in the United States are now performed arthroscopically (>74%) and there has been a recent steady decline in performance of open rotator cuff repair. Concomitant acromioplasty is performed approximately half the time, and this trend is increasing slightly. These findings were consistent across age, sex, and region in the United States.

LEVEL OF EVIDENCE

IV, cross-sectional study.

Management of limited joint mobility in diabetic patients

Several rheumatologic manifestations are more pronounced in subjects with diabetes, ie, frozen shoulder, rotator cuff tears, Dupuytren's contracture, trigger finger, cheiroarthropathy in the upper limb, and Achilles tendinopathy and plantar fasciitis in the lower limb. These conditions can limit the range of motion of the affected joint, thereby impairing function and ability to perform activities of daily living. This review provides a short description of diabetes-related joint diseases, the specific pathogenetic mechanisms involved, and the role of inflammation, overuse, and genetics, each of which activates a complex sequence of biochemical alterations. Diabetes is a causative factor in tendon diseases and amplifies the damage induced by other agents as well. According to an accepted hypothesis, damaged joint tissue in diabetes is caused by an excess of advanced glycation end products, which forms covalent cross-links within collagen fibers and alters their structure and function. Moreover, they interact with a variety of cell surface receptors, activating a number of effects, including pro-oxidant and proinflammatory events. Adiposity and advanced age, commonly associated with type 2 diabetes mellitus, are further pathogenetic factors. Prevention and strict control of this metabolic disorder is essential, because it has been demonstrated that limited joint motion is related to duration of the disease and hyperglycemia. Several treatments are used in clinical practice, but their mechanisms of action are not completely understood, and their efficacy is also debated.

The effects of aging on quantitative sonographic features of rotator cuff tendons

PURPOSE

Grayscale analysis is a practical, objective, and easy way to quantify echogenicity during ultrasonography. The purpose of the current study was to measure the changes in thickness and echogenicity that result from aging of the rotator cuff and long head of the biceps tendons.

METHODS

The study comprised 45 volunteers, aged between 20 and 84 years and without history of shoulder pain. Participants were divided into three groups: young, middle-aged, and old. All subjects underwent standard ultrasonography of both shoulders. Tendon thickness and tear were recorded, and images in both transverse and longitudinal scans were taken for grayscale analysis. To reduce the attenuation effect from skin and subcutaneous fat, we used the ratio of echogenicity of the tendon to that of the reference muscle and compared the tendon echogenicity among the different age groups. Sonographic findings were also correlated with age.

RESULTS

The supraspinatus tendon was significantly thicker in elderly participants and this was positively correlated with age. Moreover, the echogenicity ratio of the supraspinatus tendon decreased in the elderly group and showed a negative correlation with age. There was a higher prevalence of supraspinatus tendon tears in the older participants.

CONCLUSIONS

Our results indicate that supraspinatus tendons became thickened, hypoechogenic, and more likely to tear with age. The study presents a simple and useful method to investigate the echogenicity of the rotator cuff quantitatively.

A survey of the McKenzie Classification System in the Extremities: prevalence of mechanical syndromes and preferred loading strategies

BACKGROUND

Classification of patients with extremity problems is commonly based on patho-anatomical diagnoses, but problems exist regarding reliability and validity of the tests and diagnostic criteria used. Alternatively, a classification system based on patient response to repeated loading strategies can be used to classify and direct management.

OBJECTIVE

The purpose of this study was to investigate the prevalence of McKenzie's classification categories among patients with extremity problems and the loading strategies used in their management.

DESIGN

This was a prospective, observational study.

METHODS

Thirty therapists among 138 invited (response rate=22%) with a Diploma in Mechanical Diagnosis and Therapy (MDT) were identified from the McKenzie Institute International registry and recruited worldwide to complete an e-mailed questionnaire. They provided data about their age, years qualified, years since gaining a diploma, and practice, and prospectively provided data on anatomical site and categorization for 15 consecutive patients with extremity problems.

RESULTS

Data were gathered on 388 patients; classification categories were as follows: derangement (37%); contractile dysfunction (17%); articular dysfunction (10%); and "other" (36%), of which 20% were postsurgery or posttrauma. Exercise management strategies and syndrome application varied considerably among anatomical sites. Classification categories remained consistent in 85.8% of patients over the treatment episode.

LIMITATIONS

These findings are not generalizable to therapists who are not experienced with use of MDT in the extremities.

CONCLUSIONS

This study demonstrates that trained clinicians can classify patients with extremity problems into MDT classifications and that these classifications remain stable during the treatment episode. Further work is needed to test the efficacy of this system compared with other approaches, but if derangements are as common as this survey suggests, the findings have important prognostic implications because this syndrome is defined by its rapid response to repeated movements.