Rotator cuff

The purpose of this study was to evaluate the efficiency of biologic augmentation of rotator cuff repair with iliac crest bone marrow-derived mesenchymal stem cells (MSCs). The prevalence of healing and prevention of re-tears were correlated with the number of MSCs received at the tendon-to-bone interface. Forty-five patients in the study group received concentrated bone marrow-derived MSCs as an adjunct to single-row rotator cuff repair at the time of arthroscopy. The average number of MSCs returned to the patient was 51,000 ± 25,000. Outcomes of patients receiving MSCs during their repair were compared to those of a matched control group of 45 patients who did not receive MSCs. All patients underwent imaging studies of the shoulder with iterative ultrasound performed every month from the first postoperative month to the 24th month. The rotator cuff healing or re-tear was confirmed with MRI postoperatively at three and six months, one and two years and at the most recent follow up ...

Ultrasound of the shoulder is a powerful and accurate method for the examination of the rotator cuff, biceps mechanism and the synovium. This article describes the anatomy, standard examination technique, indications, pitfalls and potential errors. It lists suggested imaging algorithms for a range of shoulder pathology.

Background: Shoulder pain is a very common presentation in primary care. Evidence of benefit for subacromial corticosteroid injection is inconclusive and confined largely to studies with short follow-up. We plan a large, definitive, primary-care-based trial to determine efficacy and safety in patients with rotator cuff tendinopathy, and conducted a pilot trial to explore feasibility. Methods: Six general practitioners (GPs) from Oxfordshire, UK underwent update training in assessing painful shoulders and injecting the subacromial space. Each then recruited patients aged 35 to 74 years from primary care complaining of shoulder pain lasting no more than 6 months. Eligible participants were randomized to receive either methylprednisolone acetate 40 mg with lidocaine 1% (total volume 1 ml), or lidocaine 1% alone (total volume 1 ml), injected into the subacromial space. The participants were blinded to treatment allocation. Feasibility outcomes were rates of recruitment, withdrawal, adherence to the protocol, completeness of follow-up, and success of patient masking. Clinical outcomes were the Oxford Shoulder Score (OSS) at baseline and at 4 and 12 weeks, and responses to three satisfaction questions at 2, 4 and 12 weeks. Outcome data were collected by postal questionnaires. Results: A total of 40 participants were randomized (80% of the target 50 participants) over 26 weeks giving an overall recruitment rate of 1.5 participants per week. Rates of follow-up were maintained to a high level for the full 12 weeks. Four participants requested a 'rescue' corticosteroid injection but no patients withdrew. The trial GPs gave high scores for their confidence that the patient had remained blinded to treatment allocation during the procedure. The OSS at 4 and 12 weeks and the responses to the satisfaction questions are reported. Conclusions: It is feasible to recruit participants with shoulder pain in the primary care setting for a blinded, randomized trial of corticosteroid injection. Online randomization of participants from the practice is also feasible, and postal questionnaires provide an effective means of gathering outcome data in this area of study. The lessons learned from this pilot will usefully inform the design of a large, definitive efficacy trial in primary care.

Background: The purpose is to report the results of reverse shoulder arthroplasty (RSA) after previous failed rotator cuff surgery. Materials and methods: A retrospective multicenter study of 42 RSA in 40 patients (mean age, 71 years) with a mean follow-up of 50 months. Thirty shoulders presented with a pseudoparalytic shoulder and 12 with a painful shoulder with maintained active anterior elevation (AAE ! 90). Results: Five complications (12%) occurred and 2 patients (5%) underwent re-operation. In pseudoparalytic shoulders, AAE increased from 56 to 123 and 7% were disappointed or dissatisfied. In painful shoulders, AAE decreased from 146 to 122 and 27% were disappointed or dissatisfied. Discussion: RSA can improve function in patients with cuff deficient shoulders after failure of previous cuff surgery. However, results are inferior to primary RSA. RSA when the patient maintains greater than 90 of preoperative AAE risks loss of AAE and lower patient satisfaction.

Purpose: To report a new technique of arthroscopic biceps tenodesis using bioabsorbable interference screw fixation and the early results. Type of Study: Prospective, nonrandomized study. Methods: Technique: The principle of arthroscopic biceps tenodesis is simple: after biceps tenotomy, the tendon is exteriorized and doubled on a suture; the biceps tendon is then pulled into a humeral socket (7 or 8 mm ϫ 25 mm) drilled at the top of the bicipital groove, and fixed using a bioabsorbable interference screw (8 or 9 mm ϫ 25 mm) under arthroscopic control. Patients: 43 patients treated with this technique between 1997 and 1999 were followed-up for at least 1 year. The technique was indicated in 3 clinical situations: (1) with arthroscopic cuff repair (3 cases), (2) in case of isolated pathology of the biceps tendon with an intact cuff (6 cases), and (3) as an alternative to biceps tenotomy in patients with massive, degenerative and irreparable cuff tears (34 cases). The biceps pathology was tenosynovitis (4 cases), prerupture (15 cases), subluxation (11 cases), and luxation (13 cases). Results: The absolute Constant score improved from 43 points preoperatively to 79 points at review (P Ͻ .005). There was no loss of elbow movement and biceps strength was 90% of the strength of the other side. Two patients, operated on early in the series, presented with a rupture of the tenodesis. In both cases the bicipital tendon was very friable and the diameter of the screw proved to be insufficient (7 mm). No neurologic or vascular complications occurred. Conclusions: Arthroscopic biceps tenodesis using bioabsorbable screw fixation is technically possible and gives good clinical results. This technique can be used in cases of isolated pathologic biceps tendon or a cuff tear. A very thin, fragile, almost ruptured biceps tendon is the technical limit of this arthroscopic technique.

Deep soft-tissue infection occurs infrequently after rotator cuff repair surgery. We retrospectively reviewed the clinical presentation in 14 patients whose rotator cuff repair was complicated by an early deep infection (Ͻ6 weeks). The functional outcome after treatment in 12 of these patients was analyzed at a mean follow-up of 37.5 months (range, 11-122 months). The diagnosis of infection was most often made within 3 weeks from the date of surgery (mean, 18 days; range, 3-41 days). Common presenting symptoms included localized wound erythema and drainage. The blood leukocyte counts were usually normal, but the erythrocyte sedimentation rates and C-reactive protein levels were elevated. A mean of 2.6 surgical debridements were required to clean the wound effectively in each case. Eight of twelve patients were dissatisfied at final assessment. Most patients reported reasonably good relief of pain, but they had residual shoulder stiffness and weakness. Retention of suture anchors in the humeral head did not preclude successful eradication of the infection. (J Shoulder Elbow Surg 2005;14:1-5.)

Introduction: Shoulder stiffness is a frequent complication of surgical repair of rotator cuff tears. Post-operative stiffness negatively affects surgical outcomes leading to a substantial comorbidity and to the failure of surgical treatment. Also, a stiff shoulder could commonly be concomitant with an rotator cuff tear (RCT).

Static superior shoulder instability is associated with long-standing rotator cuff tears. Factors or mechanisms which can prevent superior migration of the humeral head, and therefore allow preservation or restoration of shoulder function despite nonanatomical cuff repair, are poorly understood. The question has therefore arisen, whether centering of the humeral head was the result of active shoulder muscle function. It was the goal of this experimental investigation to (1) determine the pattern of glenohumeral translations during active shoulder abduction measured by openmagnetic resonance imaging (MRI) techniques, and to (2) determine the influence of experimental paralysis of the infra-and supraspinatus muscles on these translations. In contrast to prior experimental investigations, the humeral head remained always centered in the glenoid fossa during active abduction. No superior migration of the humeral head could be provoked with experimental paralysis of the supra-and/or infraspinatus muscles. The hypothesis that static or dynamic superior humeral head displacement is prevented by active-supra-and/or infraspinatus muscle function must therefore be rejected, for the shoulder with a structurally intact muscle-tendon-bone unit.

We report a case of neuropraxia of the 9th, 10th and 12th cranial nerve pairs after arthroscopic rotator cuff repair in the beach chair position. The elements in the medical file seem to exclude an intracranial cause of the lesions and support a mechanical, extracranial cause due to intubation and/or the beach chair position. This clinical case report shows the neurological risks of the beach chair position during arthroscopic shoulder surgery and presents the essential safety measures to prevent these risks.

Understanding when and how much shoulder muscles are active during upper extremity sports is helpful to physicians, therapists, trainers and coaches in providing appropriate treatment, training and rehabilitation protocols to these athletes. This review focuses on shoulder muscle activity (rotator cuff, deltoids, pectoralis major, latissimus dorsi, triceps and biceps brachii, and scapular muscles) during the baseball pitch, the American football throw, the windmill softball pitch, the volleyball serve and spike, the tennis serve and volley, baseball hitting, and the golf swing. Because shoulder electromyography (EMG) data are far more extensive for overhead throwing activities compared with non-throwing upper extremity sports, much of this review focuses on shoulder EMG during the overhead throwing motion. Throughout this review shoulder kinematic and kinetic data (when available) are integrated with shoulder EMG data to help better understand why certain muscles are active during different phases of an activity, what type of muscle action (eccentric or concentric) occurs, and to provide insight into the shoulder injury mechanism. Kinematic, kinetic and EMG data have been reported extensively during overhead throwing, such as baseball pitching and football passing. Because

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The repair of chronic, massive rotator cuff tears is associated with a high rate of failure. Prospective studies comparing different repair techniques are difficult to design and carry out because of the many factors that influence structural and clinical outcomes. The objective of this study was to develop a suitable animal model for evaluation of the efficacy of different repair techniques for massive rotator cuff tears and to use this model to compare a new repair technique, tested in vitro, with the conventional technique. We compared two techniques of rotator cuff repair in vivo using the left shoulders of forty-seven sheep. With the conventional technique, simple stitches were used and both suture ends were passed transosseously and tied over the greater tuberosity of the humerus. With the other technique, the modified Mason-Allen stitch was used and both suture ends were passed transosseously and tied over a cortical-bone-augmentation device. This device consisted of a poly(L...

Objectives Treatment for degenerative rotator cuff disease of the shoulder includes physiotherapy. Dynamic humeral centering (DHC) aims at preventing subacromial impingement, which contributes to the disease. The goal of this study was to assess the effectiveness of DHC. Method 69 patients with shoulder pain and impingement syndrome were prospectively included in a single-centre randomised trial with a 12-month follow-up. Patients and assessor were blinded to the study hypothesis and treatment, respectively. DHC and non-specifi c mobilisation as control were performed for 6 weeks, in 15 supervised individual outpatient sessions, and patients performed daily home exercises. The planned primary outcome was the Constant score including subscores for pain, activity, mobility and strength at 3 months. Secondary outcomes were the Constant score and subscores at 12 months, and medication use for pain at 3 and 12 months. Results The DHC group did not differ from the control group in the total Constant score at 3 months. However, the DHC group showed a higher Constant subscore for pain (12.2 (SD 2.8) vs 9.9 (2.9), least square means difference 2.1, 95% CI 0.7 to 3.5, p=0.004). At 3 months, the DHC group also showed a higher rate of no medication use (96.7% vs 71%, proportional difference 25.7, 95% CI 3.

The triangular capsular space between the insertion tendons of the Mm. supraspinatus and subscapularis-the "rotator interval", can be divided into lateral, medio-superior and medio-inferior parts. The lateral part of the capsule is strengthened by the "Lig. semicirculare humeri" and the anterior fibres of the M. supraspinatus tendon. The Ligg. coracohumerale and "coracoglenoidale" are the macroscopical elements of the medio-superior part. The medio-inferior part of the "rotator interval" is reinforced by the Ligg. glenohumeralia superius et medium. The key ligament of the "rotator interval" is the "Lig. semicirculare humeri". Laterally it ensures the insertion of the anterior fibres of the M. supraspinatus tendon above the Lig. transversum humeri and on the Tubercula majus et minus. Medially it is the place of attachment of the Lig. coracohumerale and oblique fibres of the Lig. glenohumerale superius. The "rotator interval" is not a weak capsular region but a complex network of macroscopically recognizable tendinous and ligamentous structures.

Objectives: To determine the prevalence of soft and hard tissue abnormalities and their interrelations in the shoulders of marathon kayakers and to examine the pathoanatomical factors that predispose these athletes to injury. Methods: Fifty two long distance kayakers completed a questionnaire. Their shoulders were examined for range of motion, pain, and stability using a standard set of 10 clinical tests. The shoulder was subsequently scanned by magnetic resonance imaging (MRI) in three planes and evaluated for evidence of injury or other abnormality. The relation of clinical symptoms and MRI findings was investigated with respect to kayaker's age, number of years kayaking, and number of marathon races completed. Results: Thirty subjects were asymptomatic at the time of scanning, and twenty two showed symptoms of pain and/or instability. MRI showed acromioclavicular hypertrophy, acromial or clavicular spur, supraspinatus tendinitis, and partial tear of the supraspinatus as the most common abnormalities. Kayaker's age, number of years kayaking, and number of races completed did not relate significantly to symptoms or to the presence of an abnormality on MRI scan. Of all the pathoanatomical findings that are reported to predispose to rotator cuff injury, only acromial and clavicular spurs were found to correlate highly with supraspinatus muscle pathology. Conclusions: Rotator cuff injuries make up a large portion of the injuries seen in marathon kayakers, about twice the number reported for sprint kayakers. These injuries are the result of secondary impingement factors associated with overuse, possibly specific to kayakers, and not the result of bony restrictions around the shoulder joint. Acromioclavicular hypertrophy is a common finding in marathon kayakers, but is possibly the result of portaging or a previous injury.

Background: Augmentation of rotator cuff tears aims to strengthen the repair and reduce rerupture, yet studies still report high failure rates. This study determines key mechanical properties of rotator cuff repair patches, including establishing values for toughness and measuring the shear properties of repair patches and human rotator cuff tendons. We hypothesized that different repair grafts would (1) have varying material parameters, and (2) not all have mechanical properties similar to human rotator cuff tendons. Materials and methods: Eight specimens each from the Restore, GraftJacket, Zimmer Collagen Repair, and SportsMesh repair patches were tested to failure in tension and for suture pullout. We assessed ultimate tensile strength, tensile (Young's) modulus, and failure strain. This study also established toughness values and shear data. Storage modulus was calculated using dynamic shear analysis for the patches and 18 samples of normal rotator cuff tendon. Results: We report significant variability in important mechanical properties of repair patches, with the mechanical parameters of the patches diverting variouslydand often significantlydfrom values for human rotator cuff tendon.

Objective To evaluate the need for additional magnetic resonance imaging (MRI) following ultrasound (US) in patients with shoulder pain and/or disability and to compare the accuracy of both techniques for the detection of partial-thickness and full-thickness rotator cuff tears (RCT). Methods In 4 years, 5,216 patients underwent US by experienced musculoskeletal radiologists. Retrospectively, patient records were evaluated if MRI and surgery were performed within 5 months of US. US and MRI findings were classified into intact cuff, partial-thickness and full-thickness RCT, and were correlated with surgical findings. Results Additional MR imaging was performed in 275 (5.2%) patients. Sixty-eight patients underwent surgery within 5 months. US and MRI correctly depicted 21 (95%) and 22 (100%) of the 22 full-thickness tears, and 8 (89%) and 6 (67%) of the 9 partial-thickness tears, respectively. The differences in performance of US and MRI were not statistically significant (p = 0.15). Conclusions MRI following routine shoulder US was requested in only 5.2% of the patients. The additional value of MRI was in detecting intra-articular lesions. In patients who underwent surgery, US and MRI yielded comparably high sensitivity for detecting full-thickness RCT. US performed better in detecting partial-thickness tears, although the difference was not significant.

The impingement syndrome is defined by the compression of the rotator cuff tendons against the coracoacromial arch. Several factors contribute to this condition and they are classified as structural or functional factors. The former are changes in the coracoacromial arch, proximal humerus, bursa and rotator cuff, and the latter are related to the mechanism of the upper limb by means of synchronized activity and balanced between the rotator cuff and scapular girdle muscles. The authors report here a case of parosteal lipoma of the proximal humerus, located between the muscles deltoid, teres minor and infraspinatus causing clinical signs of impingement. It is a rare occurrence, characterized as a structural cause for the onset of this symptom.

The use of implants to provide glenohumeral soft tissue fixation has changed dramatically over the past few decades, from point tack fixation to metallic suture anchors to bioabsorbable suture anchors. Bioabsorbable suture anchors have largely replaced metallic anchors because of concerns of implant loosening, migration, and chondral injury. Although the safety and efficacy of bioabsorbable anchors has been well documented, there are numerous reports regarding the early failure related to implant bioabsorbable implant breakage or premature degradation. Patients with anchor-related complications generally present with pain and/or stiffness, and the surgeon should have a high index of suspicion if a patient does not progress as expected. Glenohumeral synovitis, glenoid osteolysis, loose bodies, and chondral injury are some of the notable complications that have been reported. Careful attention to proper anchor insertion techniques can limit the potential for complications. Newer materials, such as polyetheretherketone and other composites, have recently been introduced. These materials may address concerns of biocompatibility and material strength, but additional rigorous in vitro and in vivo trials need to be conducted before their use becomes widespread.

Purpose: To prospectively evaluate the safety and effectiveness of arthroscopic acellular human dermal matrix augmentation of large rotator cuff tear repairs. Methods: A prospective, institutional review board-approved, multicenter series of patients undergoing arthroscopic repair of 2-tendon rotator cuff tears measuring greater than 3 cm were randomized by sealed envelopes opened at the time of surgery to arthroscopic single-row rotator cuff repair with GraftJacket acellular human dermal matrix (Wright Medical Technology, Arlington, TN) augmentation (group 1) or without augmentation (group 2). Preoperative and postoperative functional outcome assessments were obtained by use of the American Shoulder and Elbow Surgeons (ASES), Constant, and University of California, Los Angeles scales. Gadoliniumenhanced magnetic resonance imaging (MRI) evaluation of these repairs was obtained at a mean of 14.5 months (range, 12 to 24 months). Adverse events were recorded. Results: There were 22 patients in group 1 and 20 in group 2 with a mean age of 56 years. The mean follow-up was 24 months (range, 12 to 38 months). The ASES score improved from 48.5 to 98.9 in group 1 and from 46.0 to 94.8 in group 2. The scores in group 1 were statistically better than those in group 2 (P ϭ .035). The Constant score improved from 41.0 to 91.9 in group 1 and from 45.8 to 85.3 in group 2. The scores in group 1 were statistically better than those in group 2 (P ϭ .008). The University of California, Los Angeles score improved from 13.3 to 28.2 in group 1 and from 15.9 to 28.3 in group 2 (P ϭ .43). Gadolinium-enhanced MRI scans showed intact cuffs in 85% of repairs in group 1 and 40% in group 2 (P Ͻ .01). No adverse events were attributed to the presence of the matrix grafts. Conclusions: Acellular human dermal matrix augmentation of large (Ͼ3 cm) cuff tears involving 2 tendons showed better ASES and Constant scores and more frequent intact cuffs as determined by gadolinium-enhanced MRI. Intact repairs were found in 85% of the augmented group and 40% of the nonaugmented group (P Ͻ .01). No adverse events related to the acellular human dermal matrix were observed. Level of Evidence: Level II, lesser-quality randomized controlled trial.

The estimation of shoulder muscle force is important to understand the mechanism of rotator cuff injury. In general, mean parameter values are used as input for computational models. However, anatomic and biomechanical parameters vary widely among people. The purpose of this study was to evaluate shoulder muscle forces predicted by an electromyography-driven muscle model given neuromuscular parameters generated by Monte Carlo simulation. Normal distributions were used to model muscle moment arms; electromyographic and muscle physiological cross-section01 area data were modeled with log-normal distributions. Eight muscles were included in the model. Muscle force and joint moment were predicted on the basis of the simulated parameters. The results showed that the subscapularis and pectoralis major were substantial actuators for shoulder internal rokrtion. During maximum vokmtary contraction the median of the muscle Forces of the subscapularis and the pectoralis major were 1030 N and 462 N, respective/y. This study demonstrated that the Monte Carlo method could be used For muscle force prediction by integrating population variability of physiological parameter into a biomechanical muscle model. p Shoulder Elbow Surg 2000;9: 188-95.) The estimation of shoulder muscle force and the analysis of the relative contribution of each muscle to shoulder joint moment are necessary for understanding the mechanism of mobility and stability of the shoulder joint, the cause of rotator cuff injury, shoulder joint subluxation and dislocation, and other shoulder joint disorders. Because the internal shoulder muscle force cannot be measured

To characterize scapular kinematics and shoulder muscle activity in patients with subacromial impingement syndrome, with and without visually identified scapular dyskinesis. Cross-sectional study. Laboratory. Participants with subacromial impingement syndrome (N=38) were visually classified using a scapular dyskinesis test with obvious scapular dyskinesis (n=19) or normal scapular motion (n=19). Not applicable. An electromagnetic motion capture system measured 3-dimensional kinematics of the thorax, humerus, and scapula. Simultaneously, surface electromyography was used to measure muscle activity of the upper, middle, and lower trapezius; serratus anterior; and infraspinatus during ascending and descending phases of weighted shoulder flexion. Separate mixed-model analyses of variance for the ascending and descending phases of shoulder flexion compared kinematics and muscle activity between the 2 groups. Shoulder disability was assessed with the Pennsylvania Shoulder Score (Penn). Th...

Although MR imaging and MR arthrography are the first choice modalities for shoulder imaging, CT arthrography (CTA) may be used successfully to address many clinical questions. The advent of submillimeter multiple detector CT technology and subsequent excellent three-plane resolution has considerably increased the quality of CTA examinations and has propelled this technique to the forefront in a growing number of indications.

Rotator cuff tears account for almost 50% of major shoulder injuries but are sometimes difficult to diagnose. To aid diagnosis, we did a prospective study, comparing results of 23 clinical tests from 400 patients with and without rotator cuff tears. Three simple tests were predictive for rotator cuff tear: supraspinatus weakness, weakness in external rotation, and impingement. When all three were positive, or if two tests were positive and the patient was aged 60 or older, the individual had a 98% chance of having a rotator cuff tear; combined absence of these features excluded this diagnosis.

Shoulder pain is a common complication after stroke that can inhibit recovery and reduce quality of life. Although neuropathic pain can affect the shoulder after stroke, this article focuses on pain resulting from shoulder pathology. Many types of shoulder pathology after stroke have been reported in the literature. No single type of shoulder pathology can account for all shoulder pain after stroke. Conversely, more than one type of shoulder pathology may cause pain within an individual stroke survivor. The pathogenesis of poststroke shoulder pain has not been studied rigorously and remains controversial. To permit readers to draw their own conclusions about controversial causes of poststroke shoulder pain, the evidence for various types of shoulder pathology reported after stroke is reviewed.

A recent study has shown that posterior rotator cuff (RC) muscles are recruited at significantly higher levels than the anterior RC during shoulder flexion. It was proposed that the mechanism whereby the posterior RC muscles were providing shoulder stability during flexion was to counterbalance potential anterior humeral head translation caused by flexion torque producing muscles. This hypothesis implies that anterior RC activity should be higher than posterior RC activity during extension to prevent posterior humeral head translation. As the normal recruitment pattern of the RC during extension has not been established, the purpose of this study was to examine this hypothesis by comparing shoulder muscle activation levels and recruitment patterns during flexion and extension exercises. Electromyographic (EMG) activity was recorded from 9 shoulder muscles in 15 volunteers. Flexion and extension exercises were performed in prone at 20%, 50%, and 70% of each participant's maximal load. A repeated measures ANOVA was used to determine differences between exercises, muscles and loads, while Pearson's correlation analysis was used to relate mean EMG patterns. During extension subscapularis and latissimus dorsi were activated at higher levels than during flexion; during flexion, supraspinatus, infraspinatus, deltoid, trapezius, and serratus anterior were more highly activated than during extension. In addition, the pattern of activity in each muscle did not vary with load. These results support the hypothesis that during flexion and extension the RC muscles are recruited in a direction specific manner to prevent potential antero-posterior humeral head translation caused by torque producing muscles.

Imbalance of the eccentrically-activated external rotator cuff muscles versus the concentrically-activated internal rotator cuff muscles is a primary risk factor for glenohumeral joint injuries in overhead activity athletes. Nonisokinetic dynamometer based strength training studies, however, have focused exclusively on resulting concentric instead of applicable eccentric strength gains of the external rotator cuff muscles. Furthermore, previous strength training studies did not result in a reduction in glenoumeral joint muscle imbalance, thereby suggesting that currently used shoulder strength training programs do not effectively reduce the risk of shoulder injury to the overhead activity athlete. Two collegiate women tennis teams, consisting of 12 women, participated in this study throughout their preseason training. One team (n = 6) participated in a 5-week, 4 times a week, external shoulder rotator muscle strength training program next to their preseason tennis training. The other team (n = 6) participated in a comparable preseason tennis training program, but did not conduct any upper body strength training. Effects of this strength training program were evaluated by comparing pre-and posttraining data of 5 maximal eccentric external immediately followed by concentric internal contractions on a Kin-Com isokinetic dynamometer (Chattecx Corp., Hixson, Tennessee). Overall, the shoulder strength training program significantly increased eccentric external total work without significant effects on concentric internal total work, concentric internal mean peak force, or eccentric external mean peak force. In conclusion, by increasing the eccentric external total exercise capacity without a subsequent increase in the concentric internal total exercise capacity, this strength training program potentially decreases shoulder rotator muscle imbalances and the risk for shoulder injuries to overhead activity athletes.

Degenerative ossification is formed directly at the major tubercle. Like in any other gliding tendon, fibrocartilage cells lie on the articular side of the rotator tendon at the pivot of the humerus head. Typically, the calcific deposits of calcifying tendinitis are found between these two areas. At this site, hydroxyapatite is usually formed by fibrocartilage cells through an unknown stimulus. There is no ossification. This is a two-phase disease. During the chronic initial phase, a calcific deposit is formed in the tendon of the rotator cuff. In the X-ray, it is clearly circumscribed and has a dense appearance (type I). Pain is inconsistent and may exist for years. In the acute phase, the deposit undergoes spontaneous resolution. Now it takes on a translucent and cloudy appearance without clear circumscription (type III). Patients experience severe pain for 2-3 weeks. Finally, a normally functioning shoulder joint will result. The X-ray therefore allows a prognostic conclusion. In...

Disease of the rotator cuff is common. It is responsible for a high proportion of patients with shoulder pain presenting to general practice, causing work absenteeism and claims for sickness benefits. Rotator cuff disease (RCD) can often be managed in primary health care services, although some cases may require secondary referral. Both extrinsic and intrinsic factors to the cuff tendon are thought to be involved in the pathogenesis leading on to a spectrum of conditions ranging from sub-acromial bursitis to mechanical failure of the cuff tendon itself. Careful history and examination followed by pertinent investigation are essential to establish the correct diagnosis. The main aim of treatment is to improve symptoms and restore function of the affected shoulder. The majority of patients suffering from RCD can be managed by conservative means, but a shift in attitude has led to a significant number benefiting from invasive procedures ranging from decompression of the sub-acromial space to large, open procedures reconstructing the tendon itself.

The understanding and treatment of shoulder instability comprise a rapidly evolving area of interest in orthopaedics. Evaluation methods are becoming more specific in showing the exact pathologies causing the symptoms. Magnetic resonance arthrography and arthroscopy have contributed to this development. The patient with an unstable shoulder should be thoroughly evaluated through their history and specific clinical tests of the shoulder as well as the scapulothoracic joint. Often, shoulder instability can be classified after this primary evaluation. Magnetic resonance arthrography and arthroscopy are the gold standards in soft-tissue evaluation, whereas specialized radiographic examinations and computed tomography scans are used to assess bony defects. Patients are treated according to the pathology found on preoperative or pretreatment evaluation. Multiple factors need to be considered before the treatment program is instituted, including the patient's age, activity demands, associated pathology and dysfunction, soft-tissue pathology, degree of instability, direction, frequency, and etiology. Treatment can be nonoperative or arthroscopic or open repair. Soft-tissue pathology and bony defects should be addressed, and the surgeon's preferred method and skills are important in choosing the right treatment for the patient. The patient should be informed about possible complications, restrictions during the treatment period, and the prognosis for the particular type of instability. To improve progress in shoulder orthopaedics, one of the most important factors can be a universal agreement on an outcome measurement tool that is well designed and validated.

Magnetic resonance imaging (MRI) evaluation of the postoperative shoulder presents technical and diagnostic challenges related to imaging artifacts from hardware and micrometallic shavings, postsurgical scarring, and morphological alterations. Improved visualization of postoperative shoulder anatomy and pathology can be obtained with the use of metal artifact reduction techniques as well as MR arthrography. In this article we review the MR techniques that are designed to address these technical and diagnostic challenges, and we discuss the definitions and indications, normal MRI appearance, and complications of routine surgical procedures for treatment of injuries to the rotator cuff, labral ligamentous complex, and biceps tendon.

The term "internal impingement" describes the normal physiological contact that occurs between the posterosuperior glenoid and the greater tuberosity in positions of hyperabduction and external rotation. This physiological contact can become symptomatic when repeated overhead motion results in partial articular-sided posterosuperior rotator cuff tears and lesions of the posterosuperior glenoid labrum. The precise pathophysiology involved with the development of symptomatic internal impingement has been debated extensively over the past few decades. However, current literature suggests that symptomatic internal impingement may result from a combination of multiple factors involving repetitive overhead activity, physiological remodeling of the throwing shoulder, posterior capsule contracture, and scapular dyskinesis, among other factors. These can all lead to scapulohumeral hyperangulation and associated pathologic findings. The purpose of this article is to review the relevant anatomy, pathophysiology, diagnosis, and management of symptomatic internal impingement through a critical review of current evidence.

Le tendon du chef long du biceps (LB) s'insère à la fois sur le tubercule supra glénoïdien de la scapula, mais aussi sur la portion supérieure du labrum. La répartition des fibres labrales et scapulaire est extrêmement variable, d'une insertion scapulaire unique à une insertion labrale prédominante [Ring ]. De même la répartition des fibres sur la partie antérieure ou postérieure du labrum varie [Sabatier (2), Cruveilhier (3), Poirier et al. (4), Testut et al. (5), Clavert et al. ( ]. Puis le tendon du LB présente son segment intra-articulaire, avant de pénétrer le sillon intertuberculaire transformé en gouttière ostéo-fibreuse par l'intervalle des rotateurs, le ligament coracohuméral, le ligament transverse et le prolongement au-delà du sillon des fibres du tendon du muscle sub-scapulaire ; le tendon du LB y est stabilisé et guidé. L'orientation, par rapport à l'axe bi-épicondylien, de l'origine du sillon est variable, tout comme sa morphologie, plus ou moins engainante pour le tendon du LB. Progressivement on observe une rétroversion de la gouttière, dessinant un 'S' italique [Hernigou et al. (7), Balg et al. (8)]. Les dimensions et la forme du tendon du LB varient en fonction de la portion considérée, il est plus large et plus aplati dans sa portion intra-articulaire, par rapport à sa partie dans la gouttière [Pfahler et al. (9), McGough et al. (10)]. Histologiquement, le LB est formé de fibres de collagène synthétisées par des ténocytes, noyées dans une substance fondamentale non spécifique. Seule la partie cheminant dans la gouttière est contenue dans une gaine synoviale. Le LB présente une vascularisation pauvre provenant de l'artère centrale qui est une artère terminale [Hermann et al. (11)] ; il est innervé par des fibres sensorielles présentes principalement au niveau du pied d'insertion du tendon, et par des fibres sympathiques sans rapport avec les fibres d'innervation vasculaire [Alpantaki et al. (12)]. Concernant maintenant le complexe labro-bicipital, sa morphologie est variable et est classée en 3 types [Ring et al. (13)]. Dans le type 1, le labrum totalement adhérent au rebord glénoïdien ; dans le type 2, le labrum présente un petit récessus inférieur, son bord libre reste arrondi et sa face inférieure majoritairement fixée au rebord glénoïdien. Dans le type 3, qui est la forme méniscale, le labrum est peu adhérent, avec un récessus inférieur important. C'est la forme dite « mobile ». Dans une étude publiée en 2005 [Clavert et al. (6)], nous avons étudié la morphologie du complexe labrobicipital et ses variations en fonction de l'âge du sujet. Nous avons conclu que de façon significative au-delà de 30 ans, la proportion de formes dites mobiles augmente. Nous souhaitons donc insister sur le fait qu'un labrum mobile et faiblement attaché au rebord glénoïdien n'est pas nécessairement pathologique, ce d'autant que le patient a plus de 30 ans.

The etiology of rotator cuff tendinopathy is multi-factorial, and has been attributed to both extrinsic and intrinsic mechanisms. Extrinsic factors that encroach upon the subacromial space and contribute to bursal side compression of the rotator cuff tendons include anatomical variants of the acromion, alterations in scapular or humeral kinematics, postural abnormalities, rotator cuff and scapular muscle performance deficits, and decreased extensibility of pectoralis minor or posterior shoulder. A unique extrinsic mechanism, internal impingement, is attributed to compression of the posterior articular surface of the tendons between the humeral head and glenoid and is not related to subacromial space narrowing. Intrinsic factors that contribute to rotator cuff tendon degradation with tensile/shear overload include alterations in biology, mechanical properties, morphology, and vascularity. The varied nature of these mechanisms indicates that rotator cuff tendinopathy is not a homogenous entity, and thus may require different treatment interventions. Treatment aimed at addressing mechanistic factors appears to be beneficial for patients with rotator cuff tendinopathy, however, not for all patients. Classification of rotator cuff tendinopathy into subgroups based on underlying mechanism may improve treatment outcomes.

Rotator cuff injury is common among baseball pitchers. The tremendous forces and torques repetitively generated at the shoulder during the throwing motion place it at risk for injury . Adolescent baseball players commonly experience shoulder pain owing to issues not seen in the adult population. In the skeletally immature thrower, the physis is the weakest structural link in the kinetic chain and poorly tolerates the biomechanical stress of throwing . Thus, injuries to the physis, such as Little League shoulder (or proximal humeral epiphysiolysis), occur frequently in young throwers. Rotator cuff injuries, however, are seen much less frequently in the adolescent athlete. Rotator cuff tears, in particular, are extremely uncommon in the pediatric population. A review of the literature yielded only 1 case of an atraumatic rotator cuff tear in anyone younger than 18 years; that case described a partial thickness tear in a 13-year-old baseball player . A case of a near full-thickness tear of the supraspinatus tendon in a 12-year-old baseball pitcher is presented.

Disease to the rotator cuff is the most common cause of shoulder pain and dysfunction in adults. This group of muscles performs multiple functions and is often stressed during various activities. The anatomy and physiology of the rotator cuff is complex and interconnected to other muscle groups in the shoulder. One must take the anatomic status of the rotator cuff tendons into account when planning the treatment of the rotator cuff injury. Diagnostic imaging of the rotator cuff, performed by MRI, provides valuable information about the nature of the injury. In this article, we will review the various types and causes of rotator cuff injuries, normal MR anatomy, function, patho-anatomy, and the biomechanics of the rotator cuff. We will also review shoulder impingement syndromes.

Recent studies have demonstrated a potentially critical role of matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) in the pathophysiology of rotator cuff tears. We hypothesize that local delivery of a MMP inhibitor after surgical repair of the rotator cuff will improve healing at the tendon-to-bone surface interface.