Comprehensive evaluation and treatment of the shoulder in the throwing athlete

Adaptive pathology: new insights into the physical examination and imaging of the thrower's shoulder and elbow

Throwing with high velocity requires extremes of glenohumeral external rotation of the abducted arm where particularly high forces in the shoulder and elbow are endured. Repeated throwing leads to dominant-arm bony remodeling of the humerus, glenoid, and elbow, and multiple soft tissue changes that would be considered abnormal. Many of these features are thought to be adaptive and protective. The purpose of this work is to (1) define the concept of adaptive pathology; (2) review the mechanics of the throwing motion; (3) review pertinent physical examination and imaging findings seen in asymptomatic throwers' shoulders and elbows and describe how these changes develop and may be adaptive-allowing the thrower to perform at high levels; and then (4) review the principles of surgical treatment in the throwing athletes, which should focus on reducing symptoms, but not necessarily restoring the thrower's anatomy to normal.

Reciprocal inhibition improves posterior shoulder tightness and shoulder range of motion in youth baseball players

Background

The aim of this study was to evaluate the efficacy of reciprocal inhibition for posterior shoulder tightness (PST), internal rotation at 90° abduction (ABIR) limitation, and subacromial impingement in elementary and junior high school baseball players.

Methods

The present study included 290 elementary school and junior high school baseball players who were members of an organized baseball team and attended a medical checkup in 2014. Seventeen participants were excluded because they were left-handed. We applied a sit-up exercise as a tool of reciprocal inhibition to all participants. Before and after the sit-up exercise, we evaluated the shoulder range of motion (ROM) in external rotation at 90° abduction (ABER), ABIR, and horizontal flexion (HF) in both shoulders and the prevalence of subacromial impingement in the dominant shoulder. We defined PST as a ≧15°decrease in the HF angle of the dominant shoulder in comparison to the nondominant shoulder before the sit-up exercise and divided participants into two groups (the PST group and the non-PST groups). An independent t-test was performed to compare the shoulder ROM, and a chi-squared test was performed to compare the prevalence of subacromial impingement between the two groups. A dependent t-test was performed to compare intragroup changes in the shoulder ROM. The McNemar test was performed to compare intragroup changes in the prevalence of subacromial impingement.

Results

Fifty-six of 273 participants had PST in the initial examination. The initial examination revealed that the ROM of ABIR and HF in the dominant shoulder were significantly lower in the PST group than those in the non-PST group, whereas the ROM of ABER and total arc were significantly higher in the PST group. The prevalence of subacromial impingement in the PST group was significantly higher than that in the non-PST group. The sit-up exercise improved ABER, ABIR, total arc, HF, and the prevalence of subacromial impingement in both groups. However, the amount of ROM change did not differ between the two groups for any parameter with the exception of HF.

Conclusion

The presence of PST affects the prevalence of subacromial impingement but was not related to the loss of ABIR or the prevalence of pathological glenohumeral internal rotation deficit. The sit-up exercise, as reciprocal inhibition, can transiently improve the prevalence of subacromial impingement via the improvement of PST.

Effect of Glenohumeral Internal Rotation Deficit on Shoulder in Baseball Pitchers during Fastball Pitching

Previous studies have reported that pitchers with glenohumeral internal rotation deficit (GIRD) may increase the risk of shoulder injury. However, limited information is available regarding the specific effects of GIRD in baseball pitching. The purpose of this study was to investigate whether baseball pitchers with GIRD change their pitching mechanism. Fifteen baseball pitchers with GIRD and 15 pitchers without GIRD were recruited from university or senior high-school teams. A three-dimensional motion analysis system (Eagle System, Motion Analysis Corporation, Santa Rosa, CA, USA) was used to capture the pitching motion while performing fastball pitches. The kinematics and kinetics of the throwing shoulder and trunk were analyzed based on motion captured data. The Mann-Whitney U test was used to test the differences of the analyzed parameters between two groups. At the instant of ball release, the GIRD group showed lower shoulder external rotation and trunk rotation, and larger shoulder horizontal adduction. In addition, the GIRD group exhibited a significantly larger shoulder inferior force in the cocking and acceleration phase, and a significantly larger internal rotation torque in the acceleration phase. The present results suggested that pitchers with GIRD need stretch training to enlarge joint range of motion, and to improve trunk strength and flexibility to alleviate potential problems associated with pitching in GIRD pitchers.

Pitcher Shoulder: Update Article

Most shoulder injuries occur due to repetitive overhead movements. Before studying the treatment of these shoulder injuries, it is paramount that health professionals have an understanding of the etiology of and the underlying mechanisms for shoulder pathologies. The act of overhead throwing is an eloquent full-body motion that requires tremendous coordination from the time of force generation to the end of the pitch. The shoulder is a crucial component of the upper-body kinetic chain, as it transmits force created in the lower body to the arm and hand to provide velocity and accuracy to the pitch.

Humeral Retroversion and Injury Risk After Proximal Humeral Epiphysiolysis (Little Leaguer's Shoulder)

BACKGROUND

The increased humeral retroversion on the dominant side of throwing athletes is thought to result from repetitive throwing motion. Little Leaguer's shoulder-a rotational stress fracture of the proximal humeral epiphyseal plate-may influence the risk of humeral retroversion and injury of the shoulder or elbow joint.

PURPOSE

To investigate the effect of Little Leaguer's shoulder on humeral retroversion and the rates of shoulder and elbow injuries.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

10 high school baseball players (average age, 16.6 years; range, 16-18 years) who had experienced Little Leaguer's shoulder during elementary or junior high school (average age, 12.6 years; range, 11-15 years) were enrolled in the study. As a control group, 22 high school baseball players (average age, 16.9 years; range, 16-18 years) who had never had any shoulder or elbow injury during elementary and junior high school were included. Humeral retroversion on ultrasonographic measurement, shoulder range of motion, and rates of shoulder and elbow injuries were evaluated.

RESULTS

Humeral retroversion was significantly greater on the dominant side than on the nondominant side in both players with Little Leaguer's shoulder (dominant, 104°± 8°; nondominant, 84°± 12°; P < .001) and controls (dominant, 91°± 13°; nondominant, 81°± 10°; P < .001). In the dominant shoulder, humeral retroversion was greater in the Little Leaguer's shoulder group than in the control group (P = .008). When the effects of humeral retroversion were excluded, maximal external rotation was significantly less in the dominant shoulder than in the nondominant shoulder in the Little Leaguer's shoulder group (by 11°± 12°, P = .02), whereas no significant difference was found between dominant (110°± 11°) and nondominant (111°± 13°) shoulders in the control group (P = .64). The rates of shoulder and elbow pain were significantly higher in the Little Leaguer's shoulder group (shoulder pain 80%, elbow pain 70%) than in the control group (shoulder pain 9%, P < .001; elbow pain 32%, P = .04).

CONCLUSION

Humeral retroversion was increased in baseball players without any history of shoulder or elbow injury during elementary and junior high school and was further increased in players who had had Little Leaguer's shoulder. Increased humeral retroversion after Little Leaguer's shoulder may be a risk factor for future shoulder or elbow injury.

Estimation of Shoulder Behavior From the Viewpoint of Minimized Shoulder Joint Load Among Adolescent Baseball Pitchers

BACKGROUND

During pitching, an overloaded joint reaction force exerted on the shoulder and excessive shoulder horizontal abduction at ball release are considered risk factors causing anterior shoulder pain for young baseball pitchers. Hypothesis/Purpose: The first aim was to examine the relationship between shoulder horizontal abduction position and force on the shoulder at ball release. The second was to identify the relative rotational position of the shoulder and the range of shoulder motion at ball release that minimize force on the shoulder. It was hypothesized that the amount of force on the shoulder would be exacerbated by excessive shoulder horizontal abduction.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Participants were 183 adolescent baseball pitchers (mean ± SD age, 15.5 ± 1.2 years) without shoulder/elbow problems. Each pitcher threw 5 fastballs to a catcher behind a home plate. The kinematics and kinetics of the throwing shoulder during fastball pitching were calculated with 3-dimensional measurements from 36 reflective markers. In data analysis, the correlations were calculated between the relative rotational positions of the shoulder (abduction, horizontal adduction-abduction) and the forces on the shoulder (anterior-posterior, proximal, and superior-inferior) at ball release. Subsequently, the specific rotational position and range of motion of the shoulder at ball release that minimized forces on the shoulder were determined.

RESULTS

Statistically significant correlations were identified between the magnitude of superior-inferior force on the shoulder and shoulder abduction position ( R² = 0.44, P < .001) as well as between the magnitude of anterior-posterior force on the shoulder and shoulder horizontal adduction-abduction position ( R² = 0.72, P < .001). Minimal anterior-posterior and superior-inferior forces were obtained with a combination of 80.6° of shoulder abduction and 10.7° of shoulder horizontal adduction. Any deviation >5° from this position significantly increased the anterior-posterior and superior-inferior forces on the shoulder.

CONCLUSION

Increasing shoulder horizontal abduction position significantly increased the magnitude of anterior force on the shoulder at ball release. The combination of 80.6° of shoulder abduction and 10.7° of horizontal shoulder adduction minimized the shear forces on the shoulder at this point.

CLINICAL RELEVANCE

The present data can be useful for screening pitching technique to prevent shoulder pain and injury with motion capture assessment.

Lower shoulder abduction during throwing motion may cause forceful internal impingement and decreased anterior stability

BACKGROUND

Internal impingement and decreased anterior stability, which result from shoulder capsular loosening, are common shoulder pathologies in throwing athletes. The purpose of this study was to assess the effect of shoulder abduction angle on shoulder internal impingement and anterior shoulder stability during the simulated throwing motion.

METHODS

Eight cadaveric shoulders were tested by simulating the late-cocking and acceleration phases of the throwing motion for intact and thrower's shoulder conditions. The maximal glenohumeral external rotation, anterior translation, location of the rotator cuff insertion with respect to the glenoid, length and site of internal impingement, and glenohumeral contact pressure were measured. All data were compared between shoulder abduction angles of 80°, 90°, and 100°.

RESULTS

Decreasing shoulder abduction in the simulated late-cocking phase shifted the humeral head posteriorly (P < .03) and superiorly (P < .001), decreasing the total internal impingement area between the greater tuberosity and glenoid (P = .04) and increasing the glenohumeral contact pressure during internal impingement (P = .02). In the simulated acceleration phase, anterior glenohumeral translation significantly increased as the shoulder abduction angle decreased (P < .001).

CONCLUSION

Decreasing shoulder abduction significantly increased the contact pressure during internal impingement in the simulated late-cocking phase of the throwing motion. During the simulated acceleration phase of the throwing motion, anterior glenohumeral translation significantly increased as shoulder abduction decreased.

Glenohumeral internal rotation deficit in throwing athletes: current perspectives

Glenohumeral internal rotation deficit (GIRD) is an adaptive process in which the throwing shoulder experiences a loss of internal rotation (IR). GIRD has most commonly been defined by a loss of >20° of IR compared to the contralateral shoulder. Total rotational motion of the shoulder is the sum of internal and external rotation and may be more important than the absolute value of IR loss. Pathologic GIRD has been defined as a loss of IR combined with a loss of total rotational motion. The leading pathologic process in GIRD is posterior capsular and rotator-cuff tightness, due to the repetitive cocking that occurs with the overhead throwing motion. GIRD has been associated with numerous pathologic conditions, including posterior superior labral tears, partial articular-sided rotator-cuff tears, and superior labral anterior-to-posterior tears. The mainstay of treatment for patients with GIRD is posterior capsular stretching and strengthening to improve scapular mechanics. In patients who fail nonoperative therapy, shoulder arthroscopy can be performed. Arthroscopic surgery in the high-level throwing athlete should be to restore them to their functional baseline with the minimum amount of intervention possible.

Evaluation and management of shoulder pain in skeletally immature athletes

Shoulder pain in young athletes generally is a result of poor sports technique and overuse. A number intrinsic causes of shoulder pain have been identified. Pain may also be referred to shoulder area from cervical spine, neck and chest pathology. Overuse stress injury of the proximal humeral physis is important to recognize early in order to prevent later complications. Shoulder impingement syndrome is a general term used to describe multiple underlying lesions and relatively uncommon in young athletes. In adolescent athletes, glenohumeral instability is an important underlying pathomechanical basis for shoulder pain. Other less frequent causes reviewed here include atraumatic osteolysis of the distal clavicle, long thoracic and suprascapular neuropathies.

Shoulder Injuries in the Overhead Throwing Athlete

The overhead pitching motion is a coordinated sequence of movements that subjects the shoulder to extreme forces. The ultimate goal of this complex, dynamic activity is to generate high ball velocity and accuracy. In doing so, repetitive throwing can cause adaptive and pathologic changes in the thrower's shoulder. This article reviews the relevant shoulder anatomy, the kinetic chain, and throwing mechanics, as well as common shoulder injuries and surgical options for the treating orthopedic surgeon.

Posterior Shoulder Instability

CONTEXT

Posterior shoulder instability has become more frequently recognized and treated as a unique subset of shoulder instability, especially in the military. Posterior shoulder pathology may be more difficult to accurately diagnose than its anterior counterpart, and commonly, patients present with complaints of pain rather than instability. "Posterior instability" may encompass both dislocation and subluxation, and the most common presentation is recurrent posterior subluxation. Arthroscopic and open treatment techniques have improved as understanding of posterior shoulder instability has evolved.

EVIDENCE ACQUISITION

Electronic databases including PubMed and MEDLINE were queried for articles relating to posterior shoulder instability.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

In low-demand patients, nonoperative treatment of posterior shoulder instability should be considered a first line of treatment and is typically successful. Conservative treatment, however, is commonly unsuccessful in active patients, such as military members. Those patients with persistent shoulder pain, instability, or functional limitations after a trial of conservative treatment may be considered surgical candidates. Arthroscopic posterior shoulder stabilization has demonstrated excellent clinical outcomes, high patient satisfaction, and low complication rates. Advanced techniques may be required in select cases to address bone loss, glenoid dysplasia, or revision.

CONCLUSION

Posterior instability represents about 10% of shoulder instability and has become increasingly recognized and treated in military members. Nonoperative treatment is commonly unsuccessful in active patients, and surgical stabilization can be considered in patients who do not respond. Isolated posterior labral repairs constitute up to 24% of operatively treated labral repairs in a military population. Arthroscopic posterior stabilization is typically considered as first-line surgical treatment, while open techniques may be required in complex or revision settings.

Effect of Anterior Capsular Laxity on Horizontal Abduction and Forceful Internal Impingement in a Cadaveric Model of the Throwing Shoulder

BACKGROUND

Excessive anterior capsular laxity (elongation of the anterior capsular ligaments) causes shoulder subluxation during acceleration of the throwing motion, leading to a disabled throwing shoulder. Few biomechanical studies have investigated the relationship between anterior capsular laxity and internal impingement, another cause of the disabled throwing shoulder.

PURPOSE/HYPOTHESIS

The purpose of this study was to assess the effect of anterior capsular laxity on forceful internal impingement during the late cocking phase. The hypothesis was that excessive anterior shoulder laxity caused by elongation of the anterior capsular ligaments will increase the horizontal abduction angle to increase glenohumeral contact pressure.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight fresh-frozen cadaveric shoulders were tested with the shoulder abducted to 90° and at maximal external rotation to simulate the late cocking phase of the throwing motion. The angle of external rotation, anterior translation, angle of horizontal abduction, locations of the articular insertion of the rotator cuff tendons (supraspinatus and infraspinatus) on the greater tuberosity relative to the glenoid, and the glenohumeral contact pressure and area during internal impingement were measured. All data were compared between intact and elongated anterior capsule, which was created by repeatedly applying external rotational stretching.

RESULTS

Elongation of the anterior capsular ligaments was confirmed by the increase in glenohumeral external rotation and anterior translation after our stretching technique. Location data showed that the posterior half of supraspinatus tendon, the entire infraspinatus tendon, and the posterosuperior labrum were impinged between the greater tuberosity and glenoid. Maximal glenohumeral horizontal abduction (2.2% increase; P = .003) and glenohumeral contact pressure (27.3% increase; P = .04) were significantly increased in the shoulder joint with increased anterior capsular laxity as compared with the intact condition.

CONCLUSION

Increased anterior capsular laxity created by applying repetitive excessive external rotational torque significantly increased horizontal abduction and contact pressure in the glenohumeral joint. Concurrently, the supraspinatus and infraspinatus tendons and posterosuperior labrum were impinged between the greater tuberosity and glenoid.

CLINICAL RELEVANCE

Increased anterior capsular laxity may exacerbate forceful internal impingement during the late cocking phase of the throwing motion.

Superior Labrum Anterior Posterior Lesions and Associated Injuries: Return to Play in Elite Athletes

BACKGROUND

Superior labrum anterior posterior (SLAP) lesions often cause shoulder pain, dysfunction, and instability. Professional athletes require a high level of shoulder function for competition and overhead activities.

PURPOSE

To evaluate elite athletes who had arthroscopic surgery for common shoulder pathologies and SLAP lesions with a follow-up of more than 3 years. The associated intra-articular pathologies and return to play were documented.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty-five shoulders in 34 elite athletes (4 women and 30 men; mean age, 25 years [range, 18-32 years]) had arthroscopic repair of SLAP lesions and accompanying Bankart or rotator cuff tears between January 2008 and November 2011. The documentation included patient symptoms, physical examination, radiological analysis with radiographs, and magnetic resonance imaging. Shoulder function was evaluated preoperatively and at follow-up using American Shoulder and Elbow Surgeons (ASES) and Kerlan Jobe Orthopaedic Clinic (KJOC) scores. The mean follow-up was 52 months.

RESULTS

Isolated SLAP lesions were seen in 17.1% of patients, SLAP lesions and partial cuff tear occurred in 25.7%, associated Bankart lesions in 37.1%, full-thickness rotator cuff tears in 8.6%, Bankart and posterior labrum lesions in 8.6%, and Bankart and full-thickness rotator cuff tears in 2.9%. Return to play was a mean 6.4 ± 1.5 months. The mean postoperative ASES and KJOC scores were 89.6 ± 4.6 and 80.9 ± 6.8, respectively, compared with preoperative scores of 64.0 ± 7.2 and 50.5 ± 10.3 (t test, P < .01).

CONCLUSION

The majority (88.2%) of professional athletes returned to their preinjury levels. SLAP lesions may frequently occur with Bankart lesions and rotator cuff tears. A high rate of return to sport at the same level of athletic performance can be achieved by anatomic repair and effective rehabilitation.

Understanding and evaluating shoulder pain in the throwing athlete

Shoulder pain in the throwing athlete can present at any age and in any level of sport and can lead to dysfunction. A thorough evaluation of the throwing athlete can often determine the cause of symptoms, which is frequently multifactorial. Although the pathophysiology leading to pain in the shoulder of the throwing athlete is not entirely known, nonoperative modalities remain the mainstay of treatment. In general, surgical intervention should be reserved as a last resort. Effective treatment often requires collaboration among trainers, players, physicians, and therapists to determine an appropriate course of action.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The disabled throwing shoulder: spectrum of pathology-10-year update

In the 10 years since the current concept series entitled "The Disabled Throwing Shoulder: Spectrum of Pathology" was conceived and written, many studies have been reported that add much more information to the understanding of the disabled throwing shoulder (DTS). The editors of Arthroscopy and the authors of the original series believed that an update to the original series would be beneficial to provide an organized overview of current knowledge that could update the thought process regarding this problem, provide better assessment and treatment guidelines, and guide further research. A dedicated meeting, including current published researchers and experienced clinicians in this subject, was organized by the Shoulder Center of Kentucky. The meeting was organized around 5 areas of the DTS that were highlighted in the original series and appear to be key in creating the DTS spectrum and to understanding and treating the DTS: (1) the role of the kinetic chain; (2) the role and clinical evaluation of the scapula; (3) the role of deficits in glenohumeral rotation, glenohumeral internal rotation deficit, and total range-of-motion deficit in the causation of labral injury and DTS; (4) the role of superior labral (SLAP) injuries and rotator cuff injuries; and (5) the composition and progression of rehabilitation protocols for functional restoration of the DTS. The meeting consisted of presentations within each area, followed by discussions, and resulted in summaries regarding what is known in each area, what is not known but thought to be important, and strategies to implement and enlarge the knowledge base.

Inferior paralabral ganglion cyst of the shoulder with labral tear -- a rare cause of shoulder pain

INTRODUCTION

Paralabral ganglion cysts of the shoulder are rare, and their pathogenesis is similar to that of meniscal cysts. The paralabral cysts are most frequently reported along the posterior, superior, and anterior aspects of the glenohumeral joint and are uncommon inferiorly to the joint. These cysts rarely become evident clinically, unless they cause compression of surrounding structures, i.e. nerve.

PATIENTS AND METHODS

We report a retrospective series of five patients with inferior paralabral ganglion cysts of the shoulder without compression of the surrounding nerve which were treated during the period from March 2007 to December 2009. All these patients presented with only chronic shoulder pain as their chief complaint, and preoperative MRI showed the cyst over the inferior aspect of a torn glenoid labrum. All patients were treated by arthroscopic cystic decompression with labrum repair. All patients were re-evaluated with MRI performed at an average of 15 months postoperatively. The clinical outcome, including the Constant score, was assessed for all patients at a median of 16 months postoperatively.

RESULTS

All the five patients had remission of pain and were satisfied with the shoulder function. The postoperative MRI in all patients showed no labral cyst recurrence. The median Constant score improved from a preoperative level of 81.5 points to 98.0 points at last follow-up.

CONCLUSION

This study demonstrates that, in the absence of any nerve compression symptoms around the shoulder joint, inferior paralabral cysts with labral tear also be considered in the differential diagnosis of chronic shoulder pain. Arthroscopic repair of the cyst with repair of the labrum can lead to the disappearance of symptoms. Knowledge of this clinical condition and its imaging features is critical for a correct diagnosis of this uncommon cause of chronic shoulder pain.

LEVEL OF EVIDENCE

Level IV. Retrospective therapeutic study.

New approaches to diagnosis and arthroscopic management of partial-thickness cuff tears

Partial-thickness cuff tears (PTCTs) are increasingly recognized as a source of pain and athletic impairment, especially in overhead athletes. 1,2 Improvements in diagnostic imaging have enhanced the ability to detect and quantify partial cuff disease, and arthroscopic advances have led to novel techniques by which partial cuff tears can be repaired. 2-6 Despite increasing recognition and improved understanding of this condition, the natural history, clinical evaluation, and management of partial tears remain elusive. This is because of the disparity between the extent of partial cuff tearing and the wide variability in clinical impairment and the frequent overlay of concomitant labral and subacromial pathology. When should operating on an athlete with a partial cuff tear be considered? What percentage of cuff tear justifies repair rather than debridement? Does this threshold vary according to the athlete or sport? And if the partial tear is repaired, what can be expected in terms of return to activity, particularly in a high-level thrower? The purpose of this manuscript is to provide an overview of partial cuff tears and their evaluation and management.