Ultrasonographic findings of painful shoulders and correlation between physical examination and ultrasonographic rotator cuff tear

Hip & Knee Are the Most Litigated Orthopaedic Cases: A Nationwide 5-Year Analysis of Medical Malpractice Claims

BACKGROUND

Approximately 80% of hip and knee surgeons will face malpractice litigation. Understanding contemporary reasons for litigation and legal outcomes in our field may help surgeons deliver more effective and satisfying care, while limiting their legal exposure. This study aimed to determine: 1) which orthopaedic subspecialties were most frequently litigated; 2) malpractice damages and negligence claimed; 3) the proportion of different case outcomes; and 4) factors associated with defense verdicts.

METHODS

A nationwide database was queried for all orthopaedic medical malpractice claims (2015 to 2020), obtaining 164 claims from 17 states. Variables included were as follows: case outcome, indemnity payment, damages, negligence claimed, treatment, and patient characteristics. A binary logistic regression determined if any collected variable increased the likelihood of a defense verdict.

RESULTS

Hip and knee cases were the highest-represented (n = 49, 29.9%; knee: n = 26, 15.9%; hip: n = 23, 14.0%), followed by the spine (n = 36; 22.0%), trauma (n = 29;17.7%), hand and wrist (n = 16; 9.8%), sports (n = 16; 9.1%), foot and ankle (n = 7; 4.3%), pediatric (n = 6; 3.7%), and shoulder (n = 6; 3.7%). Within hip and knee surgery, defense verdicts occurred in 38 cases (77.6%), while 9 (18.4%) resulted in plaintiff verdicts (mean payment: $4,866,929) and 2 (4.1%) resulted in settlements (mean settlement: $1,550,000). Nonreversible damages (eg, paralysis, amputation, and death; P < .001) were associated with a decreased likelihood of a defense outcome.

CONCLUSION

Hip and knee cases were the highest-represented in orthopaedic malpractice litigation. Surgeons were more frequently found negligent when nonreversible damages occurred. Orthopaedic surgeons should be cognizant of litigation patterns while ensuring patient-centered high-quality care.

The Applicability of Provocative Functional Tests in the Diagnosis of Rotator Cuff Muscle Injuries of the Best University Athletes

Rotator cuff disease, external and internal impingement syndromes, low shoulder stability, various types of trauma, and overuse injuries are all related to sports activities. In order to check symptoms in patients with disability and shoulder pain, clinicians use different methods and diagnostic imaging assessment. The research is aimed at evaluating whether there is a difference between provocation function tests (PFT) and ultrasonographic (US) testing of muscles within the rotator cuff in elite collegiate athletes. Patients ( $n=184$ ) were recruited from university team sports selections and tested with a standardized US examination of the shoulder and five PFTs (Speed’s test, Neer’s test, Hawkins test, lift-off test, Yergason’s test). Based on the VAS pain assessment scale, 60 subjects had some pain, which was taken for further processing in the work (124 subjects did not have the presence of pain and were excluded from further processing). The US examination was conducted using Voluson 730 apparatus, by a linear probe, with the frequency in the range of 6-12 MHz. The chi-square test showed significant differences between PFT and the occurrence of shoulder muscle tendinitis for the following variables: Speed’s test and subscapularis tendinitis ( $p=0.02$ ) and Speed’s test and infraspinatus tendinitis ( $p=0.01$ ); Neer test and biceps brachii caput longum tendinitis ( $p=0.01$ ), Neer test and supraspinatus tendinitis ( $p=0.02$ ) and Neer test and infraspinatus tendinitis ( $p=0.01$ ); lift-off test and subscapularis tendinitis ( $p=0.05$ ); and Yergason’s test and biceps brachii caput longum tendinitis ( $p=0.03$ ) and Yergason’s test and subscapitis tendinitis ( $p=0.01$ ). The greatest effect of differences was observed in Neer’s test and biceps brachii caput longum tendinitis ( $\phi =0.60$ ), while the other effects can be described as medium and small in most cases. It can be concluded that functional tests are good predictors of soft tissue changes in the muscles of the rotator cuff of the shoulder. Further monitoring and analysis are needed on a larger number of athletes.

Supraspinatus pathology on MRI is associated with degree of weakness on dynamic clinical strength testing

OBJECTIVE

To analyze shoulder strength and function in patients presenting with possible supraspinatus pathology and to ascertain if these clinical findings are associated with severity of supraspinatus pathology on MRI.

MATERIALS AND METHODS

In total, 171 patients with presumptive rotator cuff pathology and with preserved strength on standard rotator cuff examination were prospectively recruited. Patients were subjected to bilateral shoulder strength testing employing dynamometry; this included isometric strength testing at 90° of abduction, followed by eccentric assessment of isotonic strength from full abduction through the full range of motion until the arm rested at the patient's side. We calculated absolute strength and symptomatic-to-asymptomatic arm (S/A) strength ratios. On subsequent shoulder MRI, supraspinatus pathology was designated into one of seven categories. The association between strength measurements and MRI findings was analyzed.

RESULTS

Increasing lesion severity on MRI was associated with both decreasing absolute strength (no tear [59.9 N] to full-thickness tear [44.2 N]; P = 0.036) and decreasing S/A strength ratios during isotonic testing (no tear [91.9%] to full-thickness tear [65.3%]; P = 0.022). In contrast, there were no significant relationships between imaging severity and absolute strength or S/A strength ratios on isometric testing.

CONCLUSION

Severity of supraspinatus pathology on MRI was associated with dynamic clinical function. These results validate the clinical correlation between MRI designations of supraspinatus pathology and function and suggest the need for future work to investigate utility of dynamic (versus isometric) rotator cuff physical examination maneuvers.

Diagnostic Accuracy of Clinical Tests for Subscapularis Tears: A Systematic Review and Meta-analysis

Background:

Previous systematic reviews and meta-analyses on the diagnostic accuracy of shoulder clinical tests do not reach conclusions regarding subscapularis tears.

Purpose:

To compare the diagnostic accuracy of commonly used clinical tests for subscapularis tears.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

An electronic literature search was conducted using Medline, Embase, and the Cochrane Library/Central. Eligibility criteria were original clinical studies reporting the diagnostic accuracy of clinical tests to diagnose the presence of rotator cuff tears involving the subscapularis.

Results:

The electronic literature search returned 2212 records, of which 13 articles were eligible. Among 8 tests included in the systematic review, the lift-off test was most frequently reported (12 studies). Four tests were eligible for meta-analysis: bear-hug test, belly-press test, internal rotation lag sign (IRLS), and lift-off test. The highest pooled sensitivity was 0.55 (95% CI, 0.28-0.79) for the bear-hug test, while the lowest pooled sensitivity was 0.32 (95% CI, 0.13-0.61), for the IRLS. In all tests, pooled specificity was >0.90.

Conclusion:

Among the 4 clinical tests eligible for meta-analysis (bear-hug test, belly-press test, IRLS, and lift-off test), all had pooled specificity >0.90 but pooled sensitivity <0.60. No single clinical test is sufficiently reliable to diagnose subscapularis tears.

Registration:

PROSPERO (CRD42019137019).

Ultrasonography of Shoulder in Rheumatoid Arthritis: A Reliability Exercise Using Consensual Definitions among Maghrebian Rheumatologists

The shoulder may be affected in a large portion of patients with rheumatoid arthritis (RA) worldwide. However, this joint does not receive the attention required during follow-up. Indeed, although numerous clinical tests for diagnosis of a painful shoulder are available, differentiating articular from peri-articular lesions may be difficult in daily practice. Fortunately, the precise diagnosis of shoulder pain in RA has benefited from a reliable imaging modality used to detect its exact origin-ultrasonography (US). This study was aimed at assessing the intra- and inter-observer reliability of ultrasonographic findings for patients with established RA with shoulder pain in a patient-based exercise as a clinical challenge among Maghrebian rheumatologist experts in US. A total of 7 operators examined 10 patients in two rounds independently and blindly of each other. Before beginning the session, all of the rheumatologists reached a consensus on sites and US settings by performing a brief exercise on a normal shoulder. Outcome Measures in Rheumatology Clinical Trials (OMERACT) definitions of US-detected pathologies were used. Each patient underwent US scanning of the painful shoulder in predefined sites based on US technical guidelines of the European Society of Musculoskeletal Radiology: long head of biceps (LHB), subscapularis recess, posterior recess and axillary recess. The presence of subdeltoid or subcoracoid bursitis or full rupture of the suprasupinatus was identified if present. Intra- and inter-observer reliability measures were calculated using the κ coefficient. Intra-observer reliability was good for gray-scale (GS) synovitis in subscapularis and posterior recesses (κ = 0.77 and 0.73, respectively). It was moderate in the presence of GS synovitis and effusion in LHB (κ =0.53 and 0.40, respectively), posterior and subscapularis recess effusion (κ = 0.56 and 0.60, respectively) and GS and power Doppler (PD) synovitis in axillary recesses (κ = 0.58 and 0.49, respectively). Inter-observer reliability was good for PD for LHB signals (κ = 0.78). It was moderate for GS for LHB synovitis (κ = 0.54). Inter-observer agreement was poor for effusion and GS synovitis for subscapularis, posterior and axillary recesses, and very poor for PD signals in these recesses. US was a reliable imaging tool for detecting tenosynovitis in the LHB. However, reliability was moderate to poor in detecting synovitis in subscapularis, posterior and axillary recesses. These findings could be optimized by standardization of sites to assess.

The new dynamic isotonic manipulation examination (DIME) is a highly sensitive secondary screening tool for supraspinatus full-thickness tears

BACKGROUND

Traditional shoulder physical examination (PE) tests have suboptimal sensitivity for detection of supraspinatus full-thickness tears (FTTs). Therefore, clinicians may continue to suspect FTTs in some patients with negative rotator cuff PE tests and turn to magnetic resonance imaging (MRI) for definitive diagnosis. Consequently, there is a need for a secondary screening test that can accurately rule out FTTs in these patients to better inform clinicians which patients should undergo MRI. The purpose of this study was to assess the ability of 2 new dynamic PE tests to detect supraspinatus pathology in patients for whom traditional static PE tests failed to detect pathology.

METHODS

We prospectively enrolled 171 patients with suspected rotator cuff pathology with negative findings on traditional rotator cuff PE, who underwent 2 new dynamic PE tests: first, measurement of angle at which the patient first reports pain on unopposed active abduction and, second, the dynamic isotonic manipulation examination (DIME). Patients then underwent shoulder magnetic resonance arthrogram. Data from the new PE maneuvers were compared with outcomes collected from magnetic resonance arthrogram reports.

RESULTS

Pain during DIME testing had a sensitivity of 96.3% and 92.6% and a negative predictive value of 96.2% and 94.9% in the coronal and scapular planes, respectively. DIME strength ≤86.0 N had a sensitivity of 100% and 96.3% and a negative predictive value of 100% and 95.7% in the coronal and scapular planes, respectively. Pain at ≤90° on unopposed active abduction in the coronal plane had a specificity of 100% and a positive predictive value of 100% for supraspinatus pathology of any kind (ie, tendinopathy, "fraying," or tearing).

CONCLUSION

DIME is highly sensitive for supraspinatus FTTs in patients with negative traditional rotator cuff PE tests for whom there is still high clinical suspicion of FTTs. Thus, this test is an excellent secondary screening tool for supraspinatus FTTs in patients for whom clinicians suspect rotator cuff pathology despite negative traditional static PE tests. Given its high sensitivity, a negative DIME test rules out supraspinatus FTT well in these patients, and can therefore better inform clinicians which patients should undergo MRI. In addition, the angle at which patients first report pain on unopposed active shoulder abduction is highly specific for supraspinatus pathology.

Does the outcome of diagnostic ultrasound influence the treatment modalities and recovery in patients with shoulder pain in physiotherapy practice? Results from a prospective cohort study

STUDY DESIGN

Prospective cohort study including patients with shoulder pain in primary care physiotherapy.

BACKGROUND

There is an increased tendency to use diagnostic ultrasound to aid the diagnostic strategy and target treatment. It is a relatively cheap and accessible imaging technique but the implications for practice and patients are unknown.

OBJECTIVES

To study the influence of diagnostic ultrasound (DUS) on diagnostic work-up, treatment modalities and recovery.

METHODS

Participants (n = 389) with a new episode of shoulder pain were assessed at baseline and followed for 6, 12 and 26 weeks. Diagnostic work-up, including the use of DUS, and treatment strategies were reported by the therapists at 3, 6 and 12 weeks.

RESULTS

Most patients (41%) were diagnosed with subacromial impingement/pain syndrome after physical examination or DUS. DUS was used in 31% of the participants. Tendinopathy was the most found abnormality in this sub-population. Patients who underwent DUS were more frequently treated using exercise therapy. Patients that not had DUS were more likely to receive massage therapy, trigger point therapy or mobilisation techniques. Logistic regression analyses did not show a significant association between DUS and recovery after 26 weeks (0.88, 95%CI:0.50-1.57). Correcting for the therapist as a confounder using a multilevel binary logistic regression did not show a significant cluster effect.

CONCLUSION

Diagnostic US as a work-up component does not seem to influence diagnosis or recovery but does influence the choice of treatment modality. Conclusions are limited to observational data. High quality randomized trials should study the effect of DUS on recovery.

Reliability of Common Provocative Tests for Shoulder Tendinitis

OBJECTIVE

Accurate and reliable shoulder tendinopathy examination maneuvers are essential for diagnosing and treating shoulder pain; however, studies have reported varying results as to the accuracy of common maneuvers. Thus, data from a large, cross-sectional study were used to systematically quantify the reliability and accuracy of clinical diagnostic tests.

METHODS

Baseline data from the WISTAH cohort study were used to evaluate inter-tester reliability and accuracy of common provocative shoulder examination tests compared with a case definition of shoulder tendinitis.

RESULTS

Inter-tester reliability showed reliable consistency between providers with kappa coefficients between 89.5% and 94.8% for all tests. However, sensitivity was generally poor (3.0% to 60.6%). Specificity was consistently high (96.2% to 99.6%).

CONCLUSION

Common shoulder provocative tests show low sensitivity but high specificity, which implies that the primary utility of examination maneuvers is for their negative predictive values.

Does My Patient With Shoulder Pain Have a Rotator Cuff Tear?: A Predictive Model From the ROW Cohort

Background:

Rotator cuff tears are the leading cause of shoulder pain and disability. However, the diagnosis of a rotator cuff tear based on patient characteristics, symptoms, and physical examination findings remains a challenge because of a lack of data. Moreover, data on the predictive ability of a combination of these characteristics and tests are not available from a large cohort of patients. Consequently, clinicians rely on expensive imaging, such as magnetic resonance imaging (MRI), to make a diagnosis.

Purpose:

To model patient characteristics, symptoms, and physical examination findings that predict a rotator cuff tear. We present a nomogram based on our predictive model that can be used in patients with shoulder pain to determine the probability of the diagnosis of a rotator cuff tear without the need for imaging.

Study Design:

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

Methods:

We recruited patients from outpatient clinics who were ≥45 years of age and who had shoulder pain of at least 4 weeks’ duration. A rotator cuff tear was diagnosed based on expert clinical impression and the presence/absence of a tear on a blinded review of MRI. Ultimately, 301 patients were included in the analysis.

Results:

A total of 123 patients (41%) had rotator cuff tears, and 178 patients (59%) did not. The predictors of the diagnosis of a rotator cuff tear included external rotation strength ratio of the affected versus unaffected shoulder (odds ratio [OR], 1.20 [95% CI, 1.08-1.34]), male sex (OR, 1.98 [95% CI, 1.10-3.56]), positive lift-off test result (OR, 4.33 [95% CI, 1.46-12.86]), and positive Jobe test result (OR, 9.19 [95% CI, 4.69-17.99]). A nomogram based on these predictor variables was plotted.

Conclusion:

Presented is a model that can accurately predict the diagnosis of a rotator cuff tear with satisfactory discrimination and calibration based on 4 variables: sex, lift-off test, Jobe test, and external rotation strength ratio. Data from this study can be used to aid in the diagnosis of a rotator cuff tear in day-to-day clinical practice in outpatient settings without the need for expensive imaging such as MRI.

The Diagnostic Accuracy of Special Tests for Rotator Cuff Tear: The ROW Cohort Study

OBJECTIVE

The aim was to assess diagnostic accuracy of 15 shoulder special tests for rotator cuff tears.

DESIGN

From February 2011 to December 2012, 208 participants with shoulder pain were recruited in a cohort study.

RESULTS

Among tests for supraspinatus tears, Jobe test had a sensitivity of 88% (95% confidence interval [CI], 80%-96%), specificity of 62% (95% CI, 53%-71%), and likelihood ratio of 2.30 (95% CI, 1.79-2.95). The full can test had a sensitivity of 70% (95% CI, 59%-82%) and a specificity of 81% (95% CI, 74%-88%). Among tests for infraspinatus tears, external rotation lag signs at 0 degrees had a specificity of 98% (95% CI, 96%-100%) and a likelihood ratio of 6.06 (95% CI, 1.30-28.33), and the Hornblower sign had a specificity of 96% (95% CI, 93%-100%) and likelihood ratio of 4.81 (95% CI, 1.60-14.49).

CONCLUSIONS

Jobe test and full can test had high sensitivity and specificity for supraspinatus tears, and Hornblower sign performed well for infraspinatus tears. In general, special tests described for subscapularis tears have high specificity but low sensitivity. These data can be used in clinical practice to diagnose rotator cuff tears and may reduce the reliance on expensive imaging.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Effect of Bedside Ultrasound on Diagnosis and Management of Patients Presenting to a Sports Medicine Clinic With Undifferentiated Shoulder Pain

The objective of this study was to determine if point-of-care sonography of the shoulder would change diagnosis or management in patients presenting to a sports medicine clinic with shoulder pain. We performed an observational, nonrandomized, nonblinded study of provider behavior when evaluating patients presenting to a sports medicine clinic with shoulder pain. The provider completed a questionnaire regarding the most likely diagnosis and management plan after he or she had performed a physical examination and radiograph(s). Following the physical examination and radiograph(s), a bedside ultrasonographic examination (BUS) was done and the provider completed a second questionnaire regarding the findings on sonography and revisions, if any, to the diagnosis and management plan. Data were collected on 42 patient encounters. BUS led to a change in diagnosis in 53% of cases. BUS led to a change in management plan in 60.4% of patients. BUS increased provider confidence in the diagnosis from 3.7 ± 0.19 (95% confidence interval [CI]) to 4.5 ± 0.21 (95% CI) on a 1 to 5 scale, with 1 being least confident and 5 being most confident. The addition of bedside sonography to the physical examination and radiographic studies of patients with undifferentiated shoulder pain resulted in a significant number of changes to the diagnosis and management plan as well as significantly increased diagnostic confidence.

Quantitative assessment of fat infiltration in the rotator cuff muscles using water-fat MRI

PURPOSE

To evaluate a chemical shift-based fat quantification technique in the rotator cuff muscles in comparison with the semiquantitative Goutallier fat infiltration classification (GC) and to assess their relationship with clinical parameters.

MATERIALS AND METHODS

The shoulders of 57 patients were imaged using a 3T MR scanner. The rotator cuff muscles were assessed for fat infiltration using GC by two radiologists and an orthopedic surgeon. Sequences included oblique-sagittal T1-, T2-, and proton density-weighted fast spin echo, and six-echo gradient echo. The iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) was used to measure fat fraction. Pain and range of motion of the shoulder were recorded.

RESULTS

Fat fraction values were significantly correlated with GC grades (P < 0.0001, κ >0.9) showing consistent increase with GC grades (grade = 0, 0%-5.59%; grade = 1, 1.1%-9.70%; grade = 2, 6.44%-14.86%; grade = 3, 15.25%-17.77%; grade = 4, 19.85%-29.63%). A significant correlation between fat infiltration of the subscapularis muscle quantified with IDEAL versus 1) deficit in internal rotation (Spearman Rank Correlation Coefficient [SRC] = 0.39, 95% confidence interval [CI] 0.13-0.60, P < 0.01) and 2) pain (SRC coefficient = 0.313, 95% CI 0.049-0.536, P = 0.02) was found but was not seen between the clinical parameters and GC grades. Additionally, only quantitative fat infiltration measures of the supraspinatus muscle were significantly correlated with a deficit in abduction (SRC coefficient = 0.45, 95% CI 0.20-0.60, P < 0.01).

CONCLUSION

An accurate and highly reproducible fat quantification in the rotator cuff muscles using water-fat magnetic resonance imaging (MRI) techniques is possible and significantly correlates with shoulder pain and range of motion.

Clinical examination of the rotator cuff

Rotator cuff tears are the leading cause of shoulder pain and shoulder-related disability and account for 4.5 million physician visits in the United States annually. A careful history and structured physical examination are often sufficient for diagnosing rotator cuff disorders. We are not aware of a clinical review article that presents a structured physical examination protocol of the rotator cuff for the interested clinician. To fill this void, we present a physical examination protocol developed on the basis of review of prior literature and our clinical experience from dedicated shoulder practices. Our protocol includes range of motion testing by using a goniometer, strength testing by using a dynamometer, and select special tests. Among the many tests for rotator cuff disorders that have been described, we chose ones that have been more thoroughly assessed for sensitivity and specificity. This protocol can be used to isolate the specific rotator cuff tendon involved. The protocol can typically be completed in 15 minutes. We also discuss the clinical implications and limitations of the physical examination maneuvers described in our protocol. This protocol is thorough yet time efficient for a busy clinical practice. It is useful in the diagnosis of rotator cuff tears, impingement syndrome, and biceps pathology.

Clinical and radiographic outcomes of failed repairs of large or massive rotator cuff tears: minimum ten-year follow-up

INTRODUCTION

Little information exists regarding the long-term outcome after structural failure of rotator cuff repair. We previously reported clinical improvement, despite a 94% rate of failure of healing, at two years of follow-up in a cohort of eighteen patients who had undergone arthroscopic repair of massive rotator cuff tears. The purpose of the present study was to evaluate the ten-year results for these patients with known structural failures of rotator cuff repairs.

METHODS

Fifteen (83%) of eighteen patients were available for follow-up at ten years. Patients were evaluated with use of the American shoulder and elbow surgeons (ASES) score, the simple shoulder test (SST), a visual analog scale pain score, and the constant score. Radiographs and sonograms were assessed.

RESULTS

The average age was 74.6 years at the time of the latest follow-up. The average ASES score was 79.4 points (range, 50 to 95 points) and the average visual analog scale pain score was 2.2 points (range, 1 to 4 points); both scores were unchanged from those at two years. The average SST score was 9.2 points (range, 6 to 12 points), and the average age-adjusted Constant score was 73.2 points (range, 58.7 to 89.7 points). Of the patients with structurally failed repairs, all but one had radiographic signs of proximal humeral migration or cuff tear arthropathy: three had Hamada grade-2 changes, five had grade-3 changes, and three had Grade-4 changes (with two having grade-4a changes and one having grade-4b changes). Ultrasound confirmed the persistence of all tears that had been seen at two years.

CONCLUSIONS

Clinical improvements and pain relief after arthroscopic rotator cuff repair of large and massive tears are durable at the time of long-term (ten-year) follow-up, despite early structural failure of repair. Shoulders had a high rate of progression of radiographic signs associated with large rotator cuff tears. These results demonstrate that healing of large rotator cuff tears is not critical for long-term satisfactory clinical results in older patients.

Motion of the shoulder complex during multiplanar humeral elevation

BACKGROUND

Many prior studies have evaluated shoulder motion, yet no three-dimensional analysis comparing the combined clavicular, scapular, and humeral motion during arm elevation has been done. We aimed to describe and compare dynamic three-dimensional motion of the shoulder complex during raising and lowering the arm across three distinct elevation planes (flexion, scapular plane abduction, and coronal plane abduction).

METHODS

Twelve subjects without a shoulder abnormality were enrolled. Transcortical pin placement into the clavicle, scapula, and humerus allowed electromagnetic motion sensors to be rigidly fixed. The subjects completed two repetitions of raising and lowering the arm in flexion, scapular, and abduction planes. Three-dimensional angles were calculated for sternoclavicular, acromioclavicular, scapulothoracic, and glenohumeral joint motions. Joint angles between humeral elevation planes and between raising and lowering of the arm were compared.

RESULTS

General patterns of shoulder motion observed during humeral elevation were clavicular elevation, retraction, and posterior axial rotation; scapular internal rotation, upward rotation, and posterior tilting relative to the clavicle; and glenohumeral elevation and external rotation. Clavicular posterior rotation predominated at the sternoclavicular joint (average, 31 degrees). Scapular posterior tilting predominated at the acromioclavicular joint (average, 19 degrees). Differences between flexion and abduction planes of humerothoracic elevation were largest for the glenohumeral joint plane of elevation (average, 46 degrees).

CONCLUSIONS

Overall shoulder motion consists of substantial angular rotations at each of the four shoulder joints, enabling the multiple-joint interaction required to elevate the arm overhead.