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Search Results for : Rotator Cuff Syndrome
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Diagnosis Therapy Rehabilitation Imaging Clinical Laboratory
The prevalence of neovascularity in patients clinically diagnosed with rotator cuff tendinopathy.
Author(s): Lewis, JS; Raza, SA; Pilcher, J; Heron, C; Poloniecki, JD
Journal: BMC Musculoskelet Disord 2010 Mar 24; Vol. 10; Page(s) 163
[Medline ID - 20025761]

BACKGROUND: Shoulder dysfunction is common and pathology of the rotator cuff tendons and subacromial bursa are considered to be a major cause of pain and morbidity. Although many hypotheses exist there is no definitive understanding as to the origin of the pain arising from these structures. Research investigations from other tendons have placed intra-tendinous neovascularity as a potential mechanism of pain production. The prevalence of neovascularity in patients with a clinical diagnosis of rotator cuff tendinopathy is unknown. As such the primary aim of this pilot study was to investigate if neovascularity could be identified and to determine the prevalence of neovascularity in the rotator cuff tendons and subacromial bursa in subjects with unilateral shoulder pain clinically assessed to be rotator cuff tendinopathy. The secondary aims were to investigate the association between the presence of neovascularity and pain, duration of sympt oms, and, neovascularity and shoulder function. METHODS: Patients with a clinical diagnosis of unilateral rotator cuff tendinopathy referred for a routine diagnostic ultrasound (US) scan in a major London teaching hospital formed the study population. At referral patients were provided with an information document. On the day of the scan (on average, at least one week later) the patients agreeing to participate were taken through the consent process and underwent an additional clinical examination prior to undergoing a bilateral grey scale and colour Doppler US examination (symptomatic and asymptomatic shoulder) using a Philips HDI 5000 Sono CT US machine. The ultrasound scans were performed by one of two radiologists who recorded their findings and the final assessment was made by a third radiologist blinded both to the clinical examination and the ultrasound examination. The findings of the radiologists who performed the scans and the blinded radiologist were compared and any disagreements were resolved by consensus. RESULTS: Twenty-six patients agreed to participate and formed the study population. Of these, 6 subjects were not included in the final assessment following the pre-scan clinical investigation. This is because one subject had complete cessation of symptoms between the time of the referral and entry into the trial. Another five had developed bilateral shoulder pain during the same period. The mean age of the 20 subjects forming the study population was 50.2 (range 32-69) years (SD = 10.9) and the mean duration of symptoms was 22.6 (range .75 to 132) months (SD = 40.1). Of the 20 subjects included in the formal analysis, 13 subjects (65%) demonstrated neovascularity in the symptomatic shoulder and 5 subjects (25%) demonstrated neovascularity in the asymptomatic shoulder. The subject withdrawn due to complete cessation of symptoms was not found to have neovascularity in either shoulder and of the 5 withdrawn due to bilateral symptoms; two subjects were found to have signs of bilateral neovascularity, one subject demonstrated neovascularity in one shoulder and two subjects in neither shoulder. CONCLUSIONS: This study demonstrated that neovascularity does occur in subjects with a clinical diagnosis of rotator cuff tendinopathy and to a lesser extent in asymptomatic shoulders. In addition, the findings of this investigation did not identify an association between the presence of neovascularity; and pain, duration of symptoms or shoulder function. Future research is required to determine the relevance of these findings.

Teres minor innervation in the context of isolated muscle atrophy.
Author(s): Friend, J; Francis, S; McCulloch, J; Ecker, J; Breidahl, W; McMenamin, P
Journal: Surg Radiol Anat 2010 Jun 25; Vol. 32, Issue 3; Page(s) 243-9
[Medline ID - 20020125]

PURPOSE: Teres minor atrophy occurs either in isolation, associated with other rotator cuff muscle pathologies or in quadrilateral space syndrome. In the latter condition, compression of the axillary nerve is the likely cause; however, the anatomy of the nerve to teres minor and how this may relate to isolated teres minor atrophy have not been extensively investigated. In light of the significance of teres minor atrophy in shoulder pathology, we performed a combined radiological and anatomical study of teres minor and its nerve supply. METHODS: Cadaveric dissection of nine shoulder specimens from eight cadavers was performed to investigate the anatomical variability in course, length and branching pattern of both the teres minor nerve and the axillary nerve. Radiological imaging and reports were analysed on all shoulder magnetic resonance images performed over a 1-week period at four radiology clinic locations in an attempt to identify the incidence of isolated teres minor atrophy and review teres minor atrophy in association with other shoulder pathology. Finally, we studied a case of isolated teres minor atrophy identified during a routine undergraduate dissection class. RESULTS: Considerable anatomical variation was noticed in cadaver dissections in the nerve(s) supplying teres minor muscle revealing several various points where it may be vulnerable to impingement or injury at along its course. Analysis of 61 shoulder MR images revealed two patients with shoulder complaints that had isolated teres minor atrophy. Case-based study of these two male patients revealed other associated shoulder injury but the presentation was markedly different and clinically distinct from quadrilateral space syndrome. CONCLUSION: Isolated teres minor atrophy is a relatively common shoulder pathology which appears to be clinically distinct from other syndromes with rotator cuff muscle atrophy including quadrilateral space syndrome. The exact aetiology is unknown but cadaveric dissection in this study suggests the considerable anatomical variation in both the origin and length of teres minor nerve(s) increase the risk of impingement and subsequent isolated teres minor atrophy.

Evidence supporting the use of physical modalities in the treatment of upper extremity musculoskeletal conditions.
Author(s): Valen, PA; Foxworth, J
Journal: Curr Opin Rheumatol 2010 Apr 20; Vol. 22, Issue 2; Page(s) 194-204
[Medline ID - 20010297]

PURPOSE OF REVIEW: To evaluate recent trials and reviews of physical modalities and conservative treatments for selected upper extremity musculoskeletal conditions for evidence supporting their use. RECENT FINDINGS: Recent evidence suggests that many localized tendinopathies are related more to degenerative than inflammatory processes. With this realization, there is increased emphasis on finding new modalities to treat tendinopathies and other localized musculoskeletal conditions that rely on other than anti-inflammatory mechanisms. Although there is good evidence to support the short-term benefits of corticosteroid injections, convincing evidence in support of other conservative treatments and modalities is generally lacking. Extracorpal shock wave therapy may have significant clinical benefit for calcific tendinitis; however, it requires intravenous sedation in most cases and does not appear to be effective in lateral epicondylitis. The most consi stent positive treatment effects for rotator cuff tendinitis were achieved by ultrasound-guided subacromial corticosteroid injection as well as manual therapy in conjunction with therapeutic exercise. SUMMARY: Although there is evidence supporting the use of several different physical modalities and conservative treatments for upper extremity musculoskeletal conditions, there is a strong need for larger, higher quality randomized controlled trials. Although most studies are able to demonstrate short-term benefits, there is a lack of high-quality data demonstrating that these conservative treatments have long-term benefits, particularly, with regard to functional outcomes.

The effect of posterior capsular tightening on peak subacromial contact pressure during simulated active abduction in the scapular plane.
Author(s): Poitras, P; Kingwell, SP; Ramadan, O; Russell, DL; Uhthoff, HK; Lapner, P
Journal: J Shoulder Elbow Surg 2010 Jun 4; Vol. 19, Issue 3; Page(s) 406-13
[Medline ID - 20004593]

HYPOTHESIS: Our hypothesis was that tightening of the posterior capsule would lead to increased subacromial pressure and increased superior translation during active abduction in the scapular plane. BACKGROUND: Subacromial impingement syndrome is a painful condition that occurs during overhead activities as the rotator cuff is compressed in the subacromial space. Unrecognized secondary causes of subacromial impingement may lead to treatment failure. Posterior capsular tightness, believed to alter glenohumeral joint kinematics, is often cited as a secondary cause of SI; however, scientific evidence is lacking. The primary objective of this study was to evaluate the effect of posterior capsular tightening on peak subacromial pressure during abduction in the scapular plane. MATERIALS AND METHODS: Ten fresh frozen shoulder specimens from deceased donors were mounted on a custom shoulder simulator. With the scapula fixed, the deltoid and rotator cuff muscles were loaded in discrete static steps with a constant ratio to elevate the humerus in the scapular plane. The treatment order (no tightening, 1-cm, and 2-cm tightening of the posterior capsule) was randomly assigned to each specimen. Peak subacromial contact pressure and glenohumeral kinematics at the peak pressure position were compared using a repeated measures analysis of variance. RESULTS: Peak subacromial pressures (mean +/- standard deviation) were similar between treatment groups: 345 +/- 152, 410 +/- 213, and 330 +/- 164 kPa for no tightening, 1-cm, and 2-cm tightening of the posterior capsule respectively (P > .05). No significant differences were found for superior or anterior translations at the peak pressure position (P > .05). DISCUSSION: Posterior capsular tightening, as a sole variable, did not contribute to a significant increase in peak subacromial pressure during abduction in the scapular plane. A similar study simulating active forward flexion is necessary to fully characterize the contribution of posterior capsular tightness to subacromial impingement. CONCLUSION: Tightening of the posterior capsule did not increase subacromial pressure, or increase superior or anterior translation during abduction in the scapular plane.

Effect of posteroinferior capsule tightness on contact pressure and area beneath the coracoacromial arch during pitching motion.
Author(s): Muraki, T; Yamamoto, N; Zhao, KD; Sperling, JW; Steinmann, SP; Cofield, RH; An, KN
Journal: Am J Sports Med 2010 Jun 15; Vol. 38, Issue 3; Page(s) 600-7
[Medline ID - 19966101]

BACKGROUND: Tightness of the posteroinferior capsule is assumed to be the cause of internal rotation loss in baseball pitchers. Although the relationship between posterior capsule and subacromial impingement has been recognized, this relationship during the baseball-pitching motion is unclear. HYPOTHESIS: Contact pressure during baseball-pitching motion increases with posterior capsule tightness. STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh-frozen shoulders were used. The peak contact pressure and area on the coracoacromial arch were measured on a custom-designed shoulder experimental device capable of 6 degrees of freedom motion. Simultaneously, the sites of peak pressure on the coracoacromial arch and humerus were observed from various angles. The posteroinferior capsule tightness was simulated by plicating the capsule in the region from 6 to 8 o'clock. The static testing positions correlated to the early cocking, late cocking, acceleration, deceleration, and follow-through phases of the pitching motion. RESULTS: The peak contact pressure during the follow-through phase (0.63 + or - 0.50 MPa) significantly increased with posteroinferior capsule tightness (1.00 + or - 0.65 MPa) (P = .014). Additionally, the contact area on the coracoacromial ligament during the follow-through phase (0.98 + or - 0.67 cm(2)) significantly increased with posteroinferior capsule tightness (1.47 + or - 0.91 cm(2)) (P < .001). The site of the peak contact pressure did not change between the 2 conditions. CONCLUSION: Our findings demonstrate that posteroinferior capsule tightness leads to higher contact pressure under the subacromial arch and increased contact area, particularly on the coracoacromial ligament during the follow-through phase. CLINICAL RELEVANCE: This tightness may affect risk of injury of the rotator cuff and its surrounding tissues by increasing subacromial contact during pitching.

The Diagnosis and Prognosis of Impingement Syndrome in the Shoulder with Using Quantitative SPECT Assessment: A Prospective Study of 73 Patients and 24 Volunteers.
Author(s): Park, JY; Park, SG; Keum, JS; Oh, JH; Park, JS
Journal: Clin Orthop Surg 2009 Dec 4; Vol. 1, Issue 4; Page(s) 194-200
[Medline ID - 19956476]

BACKGROUND: Diagnosing impingement syndrome without rotator cuff tear usually depends on the physical examination and roentgenography, and obtaining objective evidence for this condition is at best difficult. The purpose of this study was to ascertain whether quantitatively assessing this condition with using single photon emission computerized tomography (SPECT) can diagnose impingement syndrome and predict the postoperative results. METHODS: Before executing arthroscopic or open treatment, SPECT was performed on 73 patients and 24 volunteers and these people were followed up for 2 years. Any increased uptake on SPECT was investigated by using the axial view, which demonstrated the greatest uptake for the acromion, distal clavicle, greater tuberosity, lesser tuberosity and the coracoid process of the operated and non-operated sides. RESULTS: The patients who were diagnosed as having impingement syndrome with or without rotator cuff tear showed increased uptake on the operative side compared to the non-operated side in the assessed locations. The greater tuberosity of the humerus could be used for quantitative measurement as a postoperative prognostic factor. CONCLUSIONS: The bone SPECT method is useful for making the diagnosis of patients with impingement sydrome, and the results of quantitative assessment at the greater tuberosity can be used for evaluating the prognosis following the operation.

Evaluation, diagnosis, and treatment of shoulder injuries in athletes.
Author(s): Hudson, VJ
Journal: Clin Sports Med 2010 May 21; Vol. 29, Issue 1; Page(s) 19-32, table of contents
[Medline ID - 19945585]

The shoulder remains one of the more challenging joints for clinicians to clearly identify, diagnose, and treat within the athletic population. Its complexities involving the glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic joints moving in tandem require the physician and rehabilitation specialist to have a comprehensive understanding of the biomechanics and arthrokinematics associated with athletic activity. This chapter focuses on the evaluation, classification, mechanism of injury, and initial treatment of widespread shoulder injuries involved in sports.

Review of the surgical anatomy of the axillary nerve and the anatomic basis of its iatrogenic and traumatic injury.
Author(s): Apaydin, N; Tubbs, RS; Loukas, M; Duparc, F
Journal: Surg Radiol Anat 2010 Jun 25; Vol. 32, Issue 3; Page(s) 193-201
[Medline ID - 19916067]

The axillary nerve is invariably reported to be one of the most commonly injured nerves during surgical procedures of the shoulder, and the importance of protecting it cannot be overemphasized. Many researchers have tried to identify safe regions, but the results vary among published studies. The axillary nerve may also be injured during acute trauma to the shoulder or by chronic repeated trauma as has been described in the quadrilateral space syndrome. The nerve injury may occur together with shoulder dislocation and rotator cuff tear, thus comprising the so-called "unhappy triad" of the shoulder joint. Simple attention to potential variations in the origin and course of the axillary nerve and its relationship to the shoulder capsule and having a precise knowledge of "safe zones" during operations can enhance clinical outcomes. The objective of this review, therefore, is to discuss the surgical anatomy of the axillary nerve and further emphasize the clinical importance of the its injury following shoulder trauma.

Excessive glenohumeral horizontal abduction as occurs during the late cocking phase of the throwing motion can be critical for internal impingement.
Author(s): Mihata, T; McGarry, MH; Kinoshita, M; Lee, TQ
Journal: Am J Sports Med 2010 Sep 3; Vol. 38, Issue 2; Page(s) 369-74
[Medline ID - 19915100]

BACKGROUND: The objective of this study was to determine the effects of increased horizontal abduction with maximum external rotation, as occurs during the late cocking phase of throwing motion, on shoulder internal impingement. HYPOTHESIS: An increase in glenohumeral horizontal abduction will cause overlap of the rotator cuff insertion with respect to the glenoid and increase pressure between the supraspinatus and infraspinatus tendon insertions on the greater tuberosity and the glenoid. STUDY DESIGN: Controlled laboratory study. METHODS: Eight cadaveric shoulders were tested with a custom shoulder testing system with the specimens in 60 degrees of glenohumeral abduction and maximum external rotation. The amount of internal impingement was evaluated by assessing the location of the supraspinatus and infraspinatus articular insertions on the greater tuberosity relative to the glenoid using a MicroScribe 3DLX. Pressure in the posterior-superior quadrant of the glenoid was measured using Fuji prescale film. Data were obtained with the humerus in the scapular plane and 15 degrees , 30 degrees , and 45 degrees of horizontal abduction from the scapular plane. RESULTS: At 30 degrees and 45 degrees of horizontal abduction, the articular margin of the supraspinatus and infraspinatus tendons was anterior to the posterior edge of the glenoid and less than 2 mm from the glenoid rim in the lateral direction; the contact pressure was also greater than that found in the scapular plane and 15 degrees of horizontal abduction. Conclusion Horizontal abduction beyond the coronal plane increased the amount of overlap and contact pressure between the supraspinatus and infraspinatus tendons and glenoid. CLINICAL RELEVANCE: Excessive glenohumeral horizontal abduction beyond the coronal plane may cause internal impingement, which may lead to rotator cuff tears and superior labral anterior to posterior (SLAP) lesions.

Overuse and impingement syndromes of the shoulder in the athlete.
Author(s): Cowderoy, GA; Lisle, DA; O'Connell, PT
Journal: Magn Reson Imaging Clin N Am 2010 Jan 27; Vol. 17, Issue 4; Page(s) 577-93, v
[Medline ID - 19887291]

Overuse and impingement syndromes in the shoulders of athletes are predominantly caused by instability of the glenohumeral joint. Glenohumeral joint instability is usually acquired from repetitive overuse of the rotator cuff and shoulder girdle muscles, or injury of the static and dynamic stabilizers of the glenohumeral joint. Congenital hypermobility of the joint may also contribute to these syndromes in some individuals. The throwing action may lea d to a cascade of injuries to the static and dynamic stabilizers of the posterosuperior glenohumeral joint, caused by the repetitive, high-energy nature of the action rather than a specific injury. Injury to the anterosuperior stabilizers of the glenohumeral joint may also lead to anterosuperior impingement syndrome. The role of MR in overuse and impingement syndromes of the shoulder is to accurately diagnose the underlying structural changes and serves to assist the clinician in instituting the appropriate conservative or surgical treatment for individual athletes.
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