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1.  Deltoid detachment consequent to open surgical repair of massive rotator cuff tears 
International Orthopaedics  2007;32(1):81-84.
Deltoid detachment is one of the complications in open rotator cuff repair. Although it is often described, the actual prevalence, time at which it occurs and the predisposing causes are still unknown. We prospectively studied 112 patients with massive rotator cuff tears with a mean age of 67. The surgical approach was performed with a lateral para-acromial incision. Clinical assessment was performed with Constant’s method. Of the 112 patients, 9 (8%) had deltoid detachment. It occurred about 3 months after surgery. Of the nine patients, two underwent revision surgery for the deltoid trans-bone reattachment. At the follow-up, the patients with deltoid detachment had a mean increase of only 5.5 points in the Constant score compared to that of 16.9 obtained by the control group. Deltoid reattachment, performed on the two patients, provided a mean increase of 7 points only with respect to the post-operative control at the 4th month. Considering the unsatisfactory functional result consequent to deltoid detachment and the slight improvement obtained with the reattachment, we recommend the following: use suture thread thicker than #2, do not use a simple stitch and avoid extending acromioplasty to the lateral margin of the acromion.
PMCID: PMC2219931  PMID: 17410365
2.  Deltoid muscle shape analysis with magnetic resonance imaging in patients with chronic rotator cuff tears 
It seems appropriate to assume, that for a full and strong global shoulder function a normally innervated and active deltoid muscle is indispensable. We set out to analyse the size and shape of the deltoid muscle on MR-arthrographies, and analyse its influence on shoulder function and its adaption (i.e. atrophy) for reduced shoulder function.
The fatty infiltration (Goutallier stages), atrophy (tangent sign) and selective myotendinous retraction of the rotator cuff, as well as the thickness and the area of seven anatomically defined segments of the deltoid muscle were measured on MR-arthrographies and correlated with shoulder function (i.e. active abduction). Included were 116 patients, suffering of a rotator cuff tear with shoulder mobility ranging from pseudoparalysis to free mobility. Kolmogorov-Smirnov test was used to determine the distribution of the data before either Spearman or Pearson correlation and a multiple regression was applied to reveal the correlations.
Our developed method for measuring deltoid area and thickness showed to be reproducible with excellent interobserver correlations (r = 0.814–0.982).
The analysis of influencing factors on active abduction revealed a weak influence of the amount of SSP tendon (r = −0.25; p < 0.01) and muscle retraction (r = −0.27; p < 0.01) as well as the stage of fatty muscle infiltration (GFDI: r = −0.36; p < 0.01). Unexpectedly however, we were unable to detect a relation of the deltoid muscle shape with the degree of active glenohumeral abduction. Furthermore, long-standing rotator cuff tears did not appear to influence the deltoid shape, i.e. did not lead to muscle atrophy.
Our data support that in chronic rotator cuff tears, there seems to be no disadvantage to exhausting conservative treatment and to delay implantation of reverse total shoulder arthroplasty, as the shape of deltoid muscle seems only to be influenced by natural aging, but to be independent of reduced shoulder motion.
PMCID: PMC3751864  PMID: 23957805
Rotator cuff tear; Pseudoparalysis; Deltoid muscle; Myotendinous retraction
3.  Deltoid contracture: A study of nineteen cases 
Indian Journal of Orthopaedics  2008;42(2):188-191.
Deltoid contracture is not uncommon in India. Contractures of deltoid often do not have definite etiology. We have critically analyzed the condition as regards the etiopathogenesis and its surgical results.
Materials and Methods:
Nineteen patients with deltoid contracture operated between June 1990 and September 2001 were enrolled for a unicentric retrospective study. The surgery was indicated in patients with abduction deformity of more than 30° at the shoulder. The etiology of deltoid contracture was idiopathic (n = 13) intramuscular injection in deltoid muscle (n = 5) and blunt trauma (n = 1). All were operated by distal release (incision near the insertion of the deltoid muscle). The average follow-up was of 9.5 years (range 6-17 years). They were evaluated based on parameters like pain, persistence of deformity, range of shoulder movements and strength of deltoid.
All patients recovered painless full range of shoulder motion except one. The correction of deformity was achieved in all patients and there was no loss of strength of deltoid compared to the opposite side. Histology of excised tissue showed features of chronic inflammation. The complications observed were hypertrophic scar (n = 1), painful terminal restriction of shoulder movements (n = 1) and prominent vertebral border of scapula (n = 1).
Deltoid contracture has features of chronic inflammation, and the intramuscular deltoid injection is the most incriminating factor in its etiopathogenesis. The condition can be effectively managed surgically by distal release of the deltoid muscle combined with excision of the muscular fibrotic contracture band.
PMCID: PMC2759614  PMID: 19826526
Deltoid contracture; surgical release of deltoid contracture; eitopathogenesis of deltoid contracture
4.  Anatomy of Axillary Nerve and Its Clinical Importance: A Cadaveric Study 
Axillary nerve is one of the terminal branches of posterior cord of brachial plexus, which is most commonly injured during numerous orthopaedic surgeries, during shoulder dislocation & rotator cuff tear. All these possible iatrogenic injuries are because of lack of awareness of anatomical variations of the nerve. Therefore, it is very much necessary to explore its possible variations and guide the surgeons to enhance the better clinical outcome by reducing the risk and complications.
Materials and Methods:
Twenty five cadavers (20 Males & 05 Females) making 50 specimens including both right and left sides were dissected as per standard dissection methods to find the origin, course, branches, distribution & exact location of the nerve beneath the deltoid muscle from important landmarks like: posterolateral aspect of acromion process, anteromedial aspect of tip of coracoid process, midpoint of deltoid muscle insertion (deltoid tuberosity of humerus) and from the midpoint of vertical length of deltoid muscle. The measurements were recorded and tabulated.
Statistical Analysis:
The measurements were entered in Microsoft excel and mean, proportion, standard deviation were calculated by using SPSS 16th version.
The axillary nerve was found to take origin from the posterior cord of brachial plexus (100%) dividing into anterior & posterior branches in Quadrangular space (88%) and supply deltoid muscle mainly. It also gave branches to teres minor muscle, shoulder joint capsule & superolateral brachial cutaneous nerve (100%). This study concluded that the mean distance of axillary nerve from the – anteromedial aspect of tip of coracoid process, posterolateral aspect of acromion process, midpoint of deltoid insertion & from the midpoint of vertical length of deltoid muscle measured to be (in cm) as 3.56±0.51, 7.4±0.99, 6.7±0.47 & 2.45±0.48 respectively. The mean vertical distance of entering point of axillary nerve from the anterior upper, mid middle upper & posterior upper deltoid border found to be (in cm): 4.94±0.86, 5.14±0.90 & 5.44±0.95 respectively and the horizontal anterior & horizontal posterior mean distance being 4.54±0.65 & 3.22±0.53 respectively. The mean height, mean width & mean depth of Quadrangular space measured to be (in cm): 2.23±0.40, 2.19±0.22 & 1.25±0.14 respectively.
The findings were found to be highly significant when males were compared with females but not significant when sides (right & left) were compared.
PMCID: PMC4413059  PMID: 25954611
Anatomy; Axillary Nerve; Deltoid muscle; Orthopaedic surgery; Shoulder region; Quadrilateral space syndrome
5.  Restoration of Anterior-Posterior Rotator Cuff Force Balance Improves Shoulder Function in a Rat Model of Chronic Massive Tears 
The rotator cuff musculature imparts dynamic stability to the glenohumeral joint. In particular, the balance between the subscapularis anteriorly and the infraspinatus posteriorly, often referred to as the rotator cuff “force couple,” is critical for concavity compression and concentric rotation of the humeral head. Restoration of this anterior-posterior force balance after chronic, massive rotator cuff tears may allow for deltoid compensation, but no in vivo studies have quantitatively demonstrated an improvement in shoulder function. Our goal was to determine if restoring this balance of forces improves shoulder function after two-tendon rotator cuff tears in a rat model. Forty-eight rats underwent detachment of the supraspinatus and infraspinatus. After four weeks, rats were randomly assigned to three groups: no repair, infraspinatus repair, and two-tendon repair. Quantitative ambulatory measures including medial/lateral forces, braking, propulsion, and step width were significantly different between the infraspinatus and no repair group and similar between the infraspinatus and two-tendon repair groups at almost all time points. These results suggest that repairing the infraspinatus back to its insertion site without repair of the supraspinatus can improve shoulder function to a level similar to repairing both the infraspinatus and supraspinatus tendons. Clinically, a partial repair of the posterior cuff after a two tendon tear may be sufficient to restore adequate function. An in vivo model system for two-tendon repair of massive rotator cuff tears is presented.
PMCID: PMC3094494  PMID: 21308755
6.  Comparison of muscle activity in the empty-can and full-can testing positions using 18 F-FDG PET/CT 
There has been much controversy over specific tests for diagnosis of supraspinatus tendon tear. The aim of this study was to evaluate the metabolic activity of the deltoid and rotator cuff muscles while maintaining the full-can and empty-can testing positions using 2-deoxy-2-[18 F]fluoro-D-glucose (18 F-FDG) positron emission tomography (PET)/computed tomography (CT).
Ten healthy volunteers without shoulder pain or diabetes mellitus participated in this study. Following FDG injection, both arms were maintained in either the empty-can or full-can position for 10 min. PET/CT was performed 40 min after injection. Maximum standardized uptake values (SUVs) were measured in the deltoid and rotator cuff muscles on axial PET images.
The middle deltoid exhibited the most significant increase in muscle activity at both testing positions. Additionally, a significant increase in muscle activity was observed in the middle deltoid compared with the supraspinatus (P < 0.05) in the empty-can testing position. SUVs of the middle deltoid, supraspinatus, and subscapularis showed a significant increase in the empty-can testing position compared with the full-can testing position (P < 0.05).
Significantly increased activity of the supraspinatus in conjunction with the middle deltoid and subscapularis after empty-can testing may result in decreased specificity of the empty-can test in detecting isolated supraspinatus activity. The full-can test, however, may be used to test the function of the supraspinatus with the least amount of surrounding middle deltoid and subscapularis activity.
PMCID: PMC4189674  PMID: 25269645
Fluoro-D-glucose; Positron emission tomography; Empty-can test; Full-can test; Muscle activity; Rotator cuff
7.  Single-row vs. double-row arthroscopic rotator cuff repair: clinical and 3 Tesla MR arthrography results 
Arthroscopic rotator cuff repair has become popular in the last few years because it avoids large skin incisions and deltoid detachment and dysfunction. Earlier arthroscopic single-row (SR) repair methods achieved only partial restoration of the original footprint of the tendons of the rotator cuff, while double-row (DR) repair methods presented many biomechanical advantages and higher rates of tendon-to-bone healing. However, DR repair failed to demonstrate better clinical results than SR repair in clinical trials. MR imaging at 3 Tesla, especially with intra-articular contrast medium (MRA), showed a better diagnostic performance than 1.5 Tesla in the musculoskeletal setting. The objective of this study was to retrospectively evaluate the clinical and 3 Tesla MRA results in two groups of patients operated on for a medium-sized full-thickness rotator cuff tear with two different techniques.
The first group consisted of 20 patients operated on with the SR technique; the second group consisted of 20 patients operated on with the DR technique. All patients were evaluated at a minimum of 3 years after surgery. The primary end point was the re-tear rate at 3 Tesla MRA. The secondary end points were the Constant-Murley Scale (CMS), the Simple Shoulder Test (SST) scores, surgical time and implant expense.
The mean follow-up was 40 months in the SR group and 38.9 months in the DR group. The mean postoperative CMS was 70 in the SR group and 68 in the DR group. The mean SST score was 9.4 in the SR group and 10.1 in the DR group. The re-tear rate was 60% in the SR group and 25% in the DR group. Leakage of the contrast medium was observed in all patients.
To the best of our knowledge, this is the first report on 3 Tesla MRA in the evaluation of two different techniques of rotator cuff repair. DR repair resulted in a statistically significant lower re-tear rate, with longer surgical time and higher implant expense, despite no difference in clinical outcomes. We think that leakage of the contrast medium is due to an incomplete tendon-to-bone sealing, which is not a re-tear. This phenomenon could have important medicolegal implications.
Level of evidence III. Treatment study: Case–control study.
PMCID: PMC3576341  PMID: 23351978
Shoulder; Rotator cuff tear; Arthroscopic repair; MR arthrography; Clinical result
8.  Anterolateral approach for mini-open rotator cuff repair 
International Orthopaedics  2011;36(1):95-100.
This study was undertaken to introduce an anterolateral approach for mini-open rotator cuff repair and evaluate its clinical outcome and effectiveness.
We evaluated 128 consecutive cases that were repaired by mini-open repair using an anterolateral approach. There were 80 men and 48 women, with an average age of 56.2 years. Average follow-up was 25.7 months. There were eight partial-thickness, 26 small, 40 medium, 39 large and 15 massive tears. After arthroscopic glenohumeral examination and subacromial decompression, we made a 3- to 4-cm skin incision from anterolateral edge of the acromion and dissected to the raphe between the anterior and middle deltoid. The torn tendon was repaired with single- or double-row technique using suture anchors. To prevent avulsion of the deltoid from the acromion, additional suturing within the bone tunnel was performed. We retrospectively evaluated clinical outcomes using the American Shoulder and Elbow Surgeon (ASES) scoring system.
The average visual analogue scale (VAS), activity of daily living (ADL) and ASES scores improved, respectively, from 6.6, 12.0 and 36.7 preoperatively to 1.2, 26.6 and 88.2 postoperatively. There were 71 excellent, 39 good, ten fair and eight poor results. There were no statistically significant difference between final ASES scores and age, symptom duration, tear size or preoperative stiffness, but men had significantly higher final ASES scores than women (P = 0.014).
Anterolateral approach for mini-open rotator cuff repair produces satisfactory results. It may also provide better visualisation for rotator cuff tears of all sizes.
PMCID: PMC3251680  PMID: 21717201
9.  Subacromial Injection Improves Deltoid Firing in Subjects with Large Rotator Cuff Tears 
HSS Journal  2009;6(1):30-36.
Previous studies demonstrate that scapulohumeral mechanics improve after subacromial injection. However, it is unclear how injection affects muscle firing. Forty-one subjects with two-tendon rotator cuff tears and 23 volunteer subjects with normal rotator cuffs documented by ultrasonography were examined. Electromyographic activity from 12 muscles was collected during ten functional tasks. Nine symptomatic subjects with rotator cuff tears underwent subacromial injection of anesthetic and underwent repeat electromyographic examination. Subjects with rotator cuff tears demonstrate global electromyographic differences when compared to normal controls. Asymptomatic subjects with rotator cuff tears had significantly increased anterior deltoid firing when compared to symptomatic counterparts during forward shoulder elevation. After subacromial injection, symptomatic subjects demonstrate increased anterior deltoid firing. Previous in vitro and in vivo studies have suggested that pain leads to deltoid inhibition and that subacromial injection leads to improved deltoid firing and, subsequently, improved shoulder function. This study provides direct evidence that subacromial injection improves deltoid firing in symptomatic subjects with rotator cuff tears. These findings reinforce the concept that deltoid inhibition resulting from pain is an important component of the motor disability associated with rotator cuff tears.
PMCID: PMC2821485  PMID: 19763696
rotator cuff injuries; intra-articular injection; local anesthetics; electromyography; biomechanics; shoulder joint; muscle; tendon injuries; pain; adult; human
10.  Delta Reverse Polarity Shoulder Replacement: Single Surgeon Experience with a Minimum 2-Year Follow-up 
Clinics in Orthopedic Surgery  2015;7(3):359-364.
The delta reverse shoulder replacement system was developed for the treatment of rotator cuff arthropathy so that the deltoid can substitute for the deficient rotator cuff. To evaluate the results of delta reverse shoulder replacement for functional improvement and complications in a consecutive series by a single surgeon over a period of six years with a minimum follow-up of 2 years.
The data were collected retrospectively from electronic theatre records. Over a period of 6 years (2006-2012), 46 cases that fulfilled the inclusion criteria were identified. There were 34 females and 12 males. The average age of patients was 76.2 years (range, 58 to 87 years). A single surgeon performed all procedures using the anterosuperior approach. The mean follow-up time was 49 months (range, 24 to 91 months). All cases had preoperative and postoperative Constant scores. We collected the data on indications, hospital stay, and change in the Constant score, complications, and reoperation rates.
The main indication for surgery was rotator cuff arthropathy (52.2%), followed by massive rotator cuff tear (28.3%), osteoarthritis (8.7%), fractures (6.5%), and rheumatoid arthritis (4.3%). Also, 65.2% of the cases were referred by general practitioners, 26% of the cases were referred by other consultants, and 8.8% of the cases were already under the care of a shoulder surgeon. The average preoperative Constant score was 23.5 (range, 8 to 59). The average Constant score at the final follow-up was 56 (range, 22 to 83). On average, there was an improvement of 33 points in the Constant score. The improvement in the Constant score was significant (p < 0.001). We observed complications in four patients (8.6%). Three of four patients (6.5%) needed reoperation. The first complication was pulmonary embolism in the early postoperative period. The other complications included dissociation of the glenosphere from the metaglene, deltoid detachment, and stitch abscess.
This is a single-surgeon, single-approach series of 46 cases with a minimum follow-up of 2 years. At this stage, the results are encouraging with no cases of loosening, dislocation, or nerve injury.
PMCID: PMC4553285  PMID: 26330959
Shoulder; Replacement; Reverse; Polarity; Delta
11.  Muscle activation in coupled scapulohumeral motions in the high performance tennis serve 
British Journal of Sports Medicine  2007;41(11):745-749.
To evaluate muscle activation patterns in selected scapulohumeral muscles in the tennis serve. These patterns of muscle activation have not been evaluated in other studies of the tennis serve. Fine wire and surface EMG was used to calculate onset and offset timing of muscle activation.
Controlled laboratory study.
Biomechanical laboratory.
16 tennis players (age 18–40) with rated skills (National Tennis Rating Program (NTRP) rating 4.5–6.5; club tournament level or higher) were subjects.
Main outcomes measure
Dependent variables of muscle activation onset and offset as well as sequencing of the stabilising muscles of the scapula (upper trapezius, lower trapezius, serratus anterior; the muscles that position the arm) anterior deltoid and posterior deltoid; and the muscles of the rotator cuff muscles (supraspinatus, infraspinatus, teres minor) during the tennis serve motion.
Patterns of muscle activation were observed during the tennis serve motion. The serratus anterior (−287 ms before ball impact) and upper trapezius (−234 ms) were active in the early cocking phase, while the lower trapezius (−120 ms) was activated in the late cocking phase just before the acceleration phase. The anterior deltoid (−250 ms) was activated in early cocking, while the posterior deltoid (−157 ms) was activated later. The teres minor (−214 ms) was activated early in the cocking phase. The supraspinatus (−103 ms) was activated in late cocking. The infraspinatus (+47 ms after ball impact) was activated in follow‐through. All muscles except infraspinatus were activated in duration of more than 50% of the service motion.
This study demonstrates that there are patterns of activation of muscles around the scapulohumeral articulation in the normal accomplished tennis serve. Rehabilitation and conditioning programs for tennis players should be structured to restore and optimise the activation sequences (scapular stabilisers before rotator cuff), task specific functions (serratus anterior as a retractor of the scapula, lower trapezius as a scapular stabiliser in the elevated rotating arm) and duration of activation of these muscles.
PMCID: PMC2465270  PMID: 17957010
12.  Deltoid muscular flap transfer for the treatment of irreparable rotator cuff tears 
Orthopedic Reviews  2009;1(2):e15.
The purpose of this study was to evaluate the outcome of deltoid muscle flap transfer for the treatment of irreparable rotator cuff tears. In a retrospective study 20 consecutive patients were evaluated. The index procedure took place between 2000 and 2003. Fifteen patients were male, mean age was 62 years. Inclusion criterion was a rotator cuff defect Bateman grade IV. Exclusion criteria were smaller defects, shoulder instability and fractures of the injured shoulder. An open reconstruction with acromioplasty and a pedicled delta flap was performed. Follow up period was mean 42 months. Follow-up included clinical examination, Magnetic Resonance Imaging (MRI) and the Constant and Simple (CS) shoulder tests. According to the Constant shoulder test the results were good in 13 patients, fair in 5 and unsatisfactory in 2. The pre-operative Constant Score improved from mean 25.7 points (±5.3) to 72.3 (±7.8) at follow-up. The mean values for the subcategories of CS increased significantly from 3.9 to 14.4 points for pain and from 4.2 to 15.9 points for activities daily routine (p<0.05). The change in range of motion and strength were not significant (p>0.05). Results of the Simple Shoulder Test showed a significant increase of the mean values from pre-operative 4.3 to 14.7 points post-operatively. MRI showed a subacromial covering of the defect in all cases, all flaps where intact on MRI but always the flap showed marked fatty degeneration. In conclusion, the delta flap is a simple method for the repair of large defects of the rotator cuff leading to satisfying medium results.
PMCID: PMC3143977  PMID: 21808677
shoulder; rotator cuff; massive rotator cuff tear; deltoid muscle flap.
13.  Complications in Brief: Quadriceps and Patellar Tendon Tears 
Effective treatment of knee extensor mechanism disruptions requires prompt diagnosis and thoughtful decision-making with surgical and nonsurgical approaches. When surgery is chosen, excellent surgical technique can result in excellent outcomes. Complications and failures arise from missed or delayed diagnoses and from technical problems in the operating room. In particular, inappropriate surgical timing (especially late surgery), misplaced patellar drill holes, and failure to address concomitant injuries can result in complications seen when repairing a patellar or quadriceps tendon tear. We review the complications that can occur during treatment of these injuries (Table 1).Table 1Errors and complications in the treatment of quadriceps and patellar tendon tearsError/complicationClinical effectPreventionDetectionRemedyJudgment errors Missed diagnosis: patella tendon tearPatient seen in the emergency room, presumed to have a patella dislocation; sent home; delay in treatment leads to chronic extensor mechanism disruption, which can cause disability and be more difficult to treatCareful history and physical examination(1) Physical examination Infrapatellar pain Infrapatellar gap Inability to maintain full active extension Unable to perform straight leg raise Gait abnormalities: stiff knee gait or exaggerated hip elevation for swing through circumduction(2) Radiographs Abnormal patella height (alta)(3) MRI/ultrasoundEducation of physicians and ancillary staff; high index of suspicion; thorough history and physical examination Missed diagnosis: quadriceps tendon tearVery common, especially in obese patients; delay in treatment leading to chronic extensor mechanism disruption, which can cause disability and be more difficult to treatCareful history and physical examination(1) Physical examination Suprapatellar pain Suprapatellar gapInability to maintain full active extension Gait abnormalities: stiff knee gait or exaggerated hip elevation for swing through circumduction(2) Radiographs Abnormal patella height (baja)(3) MRI/ultrasoundEducation of physicians and ancillary staff; high index of suspicion; thorough history and physical examination Missed diagnosis: intact retinaculum but torn quadriceps tendonPatient able to perform weak straight leg raise as a result of intact retinaculum, but quadriceps tendon actually completely torn; lack of power leading to altered gait and joint kinematics, joint breakdown and potential subsequent traumatic injuries(1) Careful physical examination: check for extensor lag(2) Aspirate blood from knee and inject with lidocaine; then reexamine(3) Additional imaging: MRI(1) Palpable defect in soft tissues proximal to patella(2) MRIEducation of physicians and ancillary staff; high index of suspicion Missed diagnosis: multiligament knee injury, failure to recognize extensor mechanism disruptionWith severe traumatic knee injuries, clinicians may focus on ligament/bony injury and may miss extensor mechanism disruption, leading to incomplete care of injuries and significant disability(1) Careful review of imaging, particularly sagittal views(2) Thorough physical examination(1) Palpable defect in soft tissues proximal/distal to patella(2) MRIEducation of physicians and ancillary staff; high index of suspicion; thorough history and physical examination; careful review all imaging Delayed diagnosis: delayed surgeryOperating too late after injury; tendon becomes scarred down and retracted; may be difficult to perform primary repair; may require tissue grafting and multiple surgeriesPerforming surgery as soon as possible, preferably within first weekProper detection and early management; if noted too late, consider V-Y or Scuderi technique Incorrect diagnosis: partial tendon tearTendon only partially disrupted (< 10 mm separation of the tendon from bone); will heal without surgery; in one study, nonsurgical management resulted in 93% success rate [5](1) MRI(2) Ultrasound(3) Physical examination(1) Patient should be able to maintain full active extension(2) Radiographs: normal patellar heightThis individual can be treated nonoperatively with immobilization until the tendon has healed Incorrect diagnosis: retinaculum torn, but quadriceps tendon intactAs long as the tendon is intact, the retinaculum should heal nonoperatively(1) Careful physical examination(2) Aspirate blood from knee and inject with lidocaine; then reexamine(3) Additional imaging: MRI or ultrasound Incorrect diagnosis: inability to extend knee or perform straight leg raise, but extensor mechanism is intactMultiple reasons:(1) Femoral nerve palsy(2) Pain(3) Intraarticular pathology: locked knee (loose body, bucket handle meniscal tear, etc)(1) Thorough history and careful physical examination(2) Additional imaging: MRIConsider aspiration/injection of local anesthetic and reexaminationPotential judgment errors Performing definitive surgery in open injuryConsider staged procedure if contaminated wound(1) Irrigation and debridement(2) Definitive fixationThorough history and careful physical examinationSingle stage management of contaminated or chronically open injuries potentially leads to infection and repair failure Failure to account for diabetesPoor tissue quality that should be accounted for. Delayed wound and tendon healingThorough history and careful physical examination. Tight perioperative glycemic controlLaboratory studies. Patient’s glycemic historyConsultation with patient’s primary care provider/internal medicineAdequate diseased tendon debridement.Delayed postoperative motion to account for expected delayed healingTechnical errors Positioning and preparing(1) Supine, bump under ipsilateral hip to internally rotate lower extremity(2) Consider full muscle paralysis to aid in reduction Inadequate exposureGenerous midline incision needed to see extent of injury (retinacular injury) and define injury pattern (midsubstance tear versus avulsion from patella) Failure to identify correct injury pattern: patellar tendonThree injury patterns based on location:(1) Avulsion (with/without bone) from inferior pole patella(2) Midsubstance rupture(3) Distal avulsion from tibial tubercle(1) Preoperative imaging(2) Adequate exposureCorrectly identifying injury pattern will dictate fixation method Failure to identify correct injury pattern: quadriceps tendonThree injury patterns based on location:(1) Avulsion (with/without bone) from superior pole patella(2) Midsubstance rupture(3) Mixed(1) Preoperative imaging(2) Adequate exposureCorrectly identifying injury pattern will dictate preoperative planning and fixation method Failure to débride patella/quadriceps tendon stumpFailure to débride scar or devascularized tissue may predispose to failure of the repair and/or chronic weaknessRongeur scar tissue from patellaPrepare bleeding bone bed: curette or burr a trough Failure to débride/prepare patella bone bedFailure to débride patella bone bed may predispose to poor healingRongeur scar tissue from patellaPrepare bleeding bone bed: curette or burr a trough Tendon repair: inadequate tissue for repair of midsubstance rupturesCan be challenging, especially with severely disrupted patella tendonsConsider augmentation with contralateral hamstring autograft or allograft; role for other biologics (dermal patches, etc)? Tendon repair: appropriate tension for midsubstance rupturesCan be challenging, especially with severely disrupted patella tendonsLateral radiograph of contralateral leg can help determine appropriate tension Transosseous tendon repair: divergent tunnelsDivergent tunnels lead to asymmetric reduction of tendon to bone; may lead to poor contact and therefore poor healing or maltracking(1) Adequate exposure of entire patella(2) Parallel pin drill guide(3) Consider use of fluoroscopy Transosseous tendon repair: tunnel penetration into articular surfaceIatrogenic articular cartilage injury(1) Adequate exposure of entire patella(2) Parallel pin drill guide Transosseous tendon repair: drill breakageBroken drill bit in tunnel(1) Careful drilling technique(2) Do not attempt to change direction of drill hole once started drilling(3) Do not torque drill(4) Use stout drill bit Transosseous tendon repair: anterior placement of tunnelsMay lead to downward tilting of the patella and increase patellofemoral contact forces and pain(1) Place drill holes in center of patella (with respect to AP)(2) If have to cheat, cheat toward articular surface Transosseous tendon repair: overtightening repairMay lead to patella alta or baja(1) Prepare opposite leg to assist with tensioning(2) Obtain intraoperative radiograph and compare with contralateral side Transosseous tendon repair: undertightening repair(1) May lead to patella alta or baja(2) Poor tendon to bone contact may interfere with healing(1) When tying knots, make sure to remove all the slack and that the tendon is pulled snuggly into patella bone trough(2) Adequate retinacular repair Transosseous tendon repair: prominent proximal suture knotsMay lead to skin irritationAttempt to bury knots and cover with surrounding soft tissue Suture anchor tendon repairAdvantages:(1) Less dissection(2) Decreased surgical time(3) More accurate suture placement(4) Low profile Suture anchor tendon repair: anchor pulloutCauses:(1) Poorly placed anchors(2) Poor bone quality(3) Weak anchors(1) Anchors should be placed in center of patella [2](2) Not to be used in osteoporotic bone(3) Two 5.0-mm corkscrew titanium anchors (equivalent pullout to transosseous tunnels) [1] Suture anchor tendon repair: proud anchorsProud anchors will not allow the tendon edge to be pulled into the bone trough in the patella, possibly leading to a gap at the bone-tendon junction and poor healingAnchors should be slightly countersunk to pull tendon firmly into bone trough in patella Failure to repair retinacular tissueMay lead to increased stress on central repair(1) Adequate exposure(2) Suture medial and lateral retinaculumAdditional complications Infection(1) Open injury(2) Comorbidities  Diabetes  Smoking  Chronic disease(1) Irrigation and debridement (consider delayed repair)(2) Timely administration preoperative antibiotics(3) Tight glucose control(4) Smoking cessation Wound complications(1) Open injury(2) Comorbidities  Diabetes  Smoking  Chronic disease(3) Prominent sutures(1) Irrigation and débridement (consider delayed repair)(2) Timely administration preoperative antibiotics(3) Tight glucose control(4) Smoking cessation Nerve injuryExtremely rareRehabilitation complications Prolonged immobilizationLeads to stiffness and decreased ROMIntraoperative assessment of maximum flexion before gapping between bone and tendon is observedEarly ROM (10–14 days): active flexion, passive extension to limits determined intraoperatively Inadequate immobilization(1) Wound complications(2) Failure of repairROM bracing locked in extension Overly aggressive physical therapyNeed time for tendon-to-bone healing to occurNo forced flexion or active extension in first 6 weeks
PMCID: PMC3916631  PMID: 24338040
14.  Variation in External Rotation Moment Arms among Subregions of Supraspinatus, Infraspinatus, and Teres Minor Muscles 
A rotator cuff tear causes morphologic changes in rotator cuff muscles and tendons and reduced shoulder strength. The mechanisms by which these changes affect joint strength are not understood. This study’s purpose was to empirically determine rotation moment arms for subregions of supraspinatus, infraspinatus, and for teres minor, and to test the hypothesis that subregions of the cuff tendons increase their effective moment arms through connections to other subregions. Tendon excursions were measured for full ranges of rotation on 10 independent glenohumeral specimens with the humerus abducted in the scapular plane at 10 and 60°. Supraspinatus and infraspinatus tendons were divided into equal width subregions. Two conditions were tested: tendon divided to the musculotendinous junction, and tendon divided to the insertion on the humerus. Moment arms were determined from tendon excursion via the principle of virtual work. Moment arms for the infraspinatus (p < 0.001) and supraspinatus (p < 0.001) were significantly greater when the tendon was only divided to the musculotendinous junction versus division to the humeral head. Moment arms across subregions of infraspinatus (p < 0.001) and supraspinatus (p < 0.001) were significantly different. A difference in teres minor moment arm was not found for the two cuff tendon conditions. Moment arm differences between muscle subregions and for tendon division conditions have clinical implications. Interaction between cuff regions could explain why some subjects retain strength after a small cuff tear. This finding helps explain why a partial cuff repair may be beneficial when a complete repair is not possible. Data presented here can help differentiate between cuff tear cases that would benefit from cuff repair and cases for which cuff repair might not be as favorable.
PMCID: PMC1551907  PMID: 16779813
shoulder; external rotation; moment arm; infraspinatus; teres minor; supraspinatus
15.  MRI findings in Painful Post-stroke Shoulder 
Background and Purpose
Describe the structural abnormalities in the painful shoulder of stroke survivors and their relationships to clinical characteristics.
Eight-nine chronic stroke survivors with post-stroke shoulder pain underwent T1 and T2 weighed multiplanar, multisequence magnetic resonance imaging of the painful paretic shoulder. All scans were reviewed by one radiologist for the following abnormalities: rotator cuff, biceps and deltoid tears, tendonopathies and atrophy, subacromial bursa fluid, labral ligamentous complex abnormalities, and acromio-clavicular capsular hypertrophy. Clinical variables included subject demographics, stroke characteristics and the Brief Pain Inventory Questions 12 (BPI 12). The relationship between MRI findings and clinical characteristics were assessed via logistic regression.
Thirty-five percent of subjects exhibited a tear of at least 1 rotator cuff, biceps or deltoid muscle. Fifty-three percent of subjects exhibited tendonopathy of at least 1 rotator cuff, bicep or deltoid muscle. The prevalence of rotator cuff tears increased with age. However, rotator cuff tears and rotator cuff and deltoid tendonopathies were not related to severity of post-stroke shoulder pain. In approximately 20% of cases, rotator cuff and deltoid muscles exhibited evidence of atrophy. Atrophy was associated with reduced motor strength and reduced severity of shoulder pain.
Rotator cuff tears and rotator cuff and deltoid tendonopathies are highly prevalent in post-stroke shoulder pain. However, their relationship to shoulder pain is uncertain. Atrophy is less common, but is associated with less severe shoulder pain.
PMCID: PMC2398766  PMID: 18388345
Shoulder pain; Magnetic Resonance Imaging
16.  Recurrent anterior shoulder instability: Review of the literature and current concepts 
The purpose of this review article is to discuss the clinical spectrum of recurrent traumatic anterior shoulder instability with the current concepts and controversies at the scientific level. Because of increasing participation of people from any age group of the population in sports activities, health care professionals dealing with the care of trauma patients must have a thorough understanding of the anatomy, patho-physiology, risk factors, and management of anterior shoulder instability. The risk factors for recurrent shoulder dislocation are young age, participation in high demand contact sports activities, presence of Hill-Sachs or osseous Bankart lesion, previous history of ipsilateral traumatic dislocation, ipsilateral rotator cuff or deltoid muscle insufficiency, and underlying ligamentous laxity. Achieving the best result for any particular patient depends on the procedure that allows observation of the joint surfaces, provides the anatomical repair, maintains range of motion, and also can be applied with low rates of complications and recurrence. Although various surgical techniques have been described, a consensus does not exist and thus, orthopedic surgeons should follow and try to improve the current evidence-based treatment modalities for the patients.
PMCID: PMC4233422  PMID: 25405191
Recurrent instability; Glenohumeral joint; Dislocation; Shoulder; Review
17.  Low-term results from non-conventional partial arthroplasty for treating rotator cuff arthroplasthy☆ 
Revista Brasileira de Ortopedia  2015;50(3):324-330.
To evaluate the evolution of the functional results from CTA® hemiarthroplasty for surgically treating degenerative arthroplathy of the rotator cuff, with a mean follow-up of 5.4 years.
Eighteen patients who underwent CTA® partial arthroplasty to treat degenerative arthroplathy of the rotator cuff between April 2007 and June 2009 were reevaluated, with minimum and mean follow-ups of 4.6 years and 5.4 years, respectively. Pre and postoperative parameters for functionality and patient satisfaction were used (functional scale of the University of California in Los Angeles, UCLA). All the patients underwent prior conservative treatment for 6 months and underwent surgical treatment because of the absence of satisfactory results. Patients were excluded if they presented any of the following: previous shoulder surgery; pseudoparalysis; insufficiency of the coracoacromial arch (type 2 B in Seebauer's classification); neurological lesions; or insufficiency of the deltoid muscle and the subscapularis muscle.
With a mean follow-up of 5.4 years, 14 patients considered that they were satisfied with the surgery (78%); the mean range of joint motion for active elevation improved from 55.8° before the operation to 82.0° after the operation; the mean external rotation improved from 18.9° before the operation to 27.3° after the operation; and the mean medial rotation remained at the level of the third lumbar vertebra. The mean UCLA score after the mean follow-up of 5.4 years was 23.94 and this was an improvement in comparison with the preoperative mean and the mean 1 year after the operation.
The functional results from CTA® hemiarthroplasty for treating rotator cuff arthroplasty in selected patients remained satisfactory after a mean follow-up of 5.4 years.
PMCID: PMC4519650
Replacement arthroplasty; Shoulder; Rotator cuff; Artroplastia de substituição; Ombro; Manguito rotador
18.  Electromyographic Analysis of the Supraspinatus and Deltoid Muscles During 3 Common Rehabilitation Exercises 
Journal of Athletic Training  2007;42(4):464-469.
Context: Investigators have observed electromyographic (EMG) activity of the supraspinatus muscle and reported conflicting results.
Objective: To quantify EMG activity of the supraspinatus, middle deltoid, and posterior deltoid muscles during exercises commonly used in rehabilitation.
Design: One-factor, repeated-measures design.
Setting: Controlled laboratory.
Patients or Other Participants: Twenty-two asymptomatic subjects (15 men, 7 women) with no history of shoulder injury participated.
Main Outcomes Measure(s): The dominant shoulder was tested. Fine-wire EMG electrodes were inserted into the supraspinatus, middle deltoid, and posterior deltoid muscles. The EMG data were collected at 960 Hz for analysis during maximal voluntary isometric contraction (MVIC) and 5 repetitions of 3 exercises: standing elevation in the scapular plane (“full can”), standing elevation in the scapular plane with glenohumeral internal rotation (“empty can”), and prone horizontal abduction at 100° with glenohumeral external rotation (“prone full can”). We calculated 1-way repeated-measures analysis of variance (P < .05) and post hoc 2-tailed, paired t tests to detect significant differences in muscle activity among exercises.
Results: No statistical difference existed among the exercises for the supraspinatus. The middle deltoid showed significantly greater activity during the empty-can exercise (77 ± 44% MVIC) and prone full-can exercise (63 ± 31% MVIC) than during the full-can exercise (52 ± 27% MVIC) (P = .001 and .017, respectively). The posterior deltoid showed significantly greater activity during the prone full-can exercise (87 ± 53% MVIC) than during the full-can (P = .001) and the empty-can (P = .005) exercises and significantly greater activity during the empty-can exercise (54 ± 24% MVIC) than during the full-can exercise (38 ± 32% MVIC) (P = .012).
Conclusions: While all 3 exercises produced similar amounts of supraspinatus activity, the full-can exercise produced significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing. The empty-can exercise may be a good exercise to recruit the middle deltoid muscle, and the prone full-can exercise may be a good exercise to recruit the posterior deltoid muscle.
PMCID: PMC2140071  PMID: 18174934
shoulder; dynamic stabilization; empty-can exercises; full-can exercises; prone full-can exercises; rotator cuff; scaption
19.  Comparison of the Effects of Local Cryotherapy and Passive Cross-Body Stretch on Extensibility in Subjects with Posterior Shoulder Tightness 
The objective was to compare the immediate effects of local cryotherapy (LC) and passive cross-body stretch on the extensibility of the posterior shoulder muscle in individuals with posterior shoulder tightness. Eighty-seven healthy subjects with a between-shoulder difference in internal rotation (IR) range of motion (ROM) greater than 10° were randomly divided into three groups: LC group, stretching group, and control group (n = 29 in each group). Subjects in the LC group received LC on infraspinatus and posterior deltoid muscles and subjects in the stretching group performed passive cross-body stretch. Stretch sensation was measured at the end range of passive IR and horizontal adduction (HA) using numerical rating scale, and the pressure pain threshold (PPT) at the infraspinatus and posterior deltoid muscles was measured using pressure algometry. Passive and active ROM of IR and HA of the glenohumeral joint were measured using an inclinometer. All measurements were performed at pre-intervention, post- intervention, and 10-min follow-up. Stretch sensation was significantly decreased and PPT was significantly increased in the LC and stretching groups at post-intervention, and these effects were maintained at 10-min follow-up, compared to the control group. Both the LC group and stretching group had a significantly greater increase in passive and active ROM of IR and HA, compared to the control group at post-intervention and 10-min follow-up. However, there were no significant differences in stretch sensation, PPT, or ROM of IR and HA between the LC group and stretching group. LC can be used to decrease the stretch sensation and increase PPT and ROM of IR and HA as much as a stretching exercise. LC could be an alternative method for increasing the restricted ROM of glenohumeral IR and HA for individuals with posterior shoulder tightness, especially for patients and sports players who have severe stretching discomfort.
Key PointsLocal cryotherapy (LC) decreased the uncomfortable stretch sensation, and increased the pressure pain threshold (PPT) of infraspinatus and posterior deltoid muscles in subjects with posterior shoulder tightness.Decreased stretch sensation by LC without passive stretching could improve the passive and active ROM of internal rotation and horizontal adduction in subjects with posterior shoulder tightness, similar to cross-body stretch.LC can be an alternative method to increase extensibility when individuals with posterior shoulder tightness have high stretch sensitivity and low PPT in the infraspinatus and posterior deltoid muscles.
PMCID: PMC3918572  PMID: 24570610
Cryotherapy; muscle stretching exercise; shoulder
20.  Anatomic Deltoid Ligament Repair with Anchor-to-Post Suture Reinforcement: Technique Tip 
The Iowa Orthopaedic Journal  2012;32:227-230.
The deltoid ligament is the primary ligamentous stabilizer of the ankle joint. Both superficial and deep components of the ligament can be disrupted with a rotational ankle fracture, chronic ankle instability, or in late stage adult acquired flatfoot deformity. The role of deltoid ligament repair in these conditions has been limited and its contribution to arthritis is largely unknown. Neglect of the deltoid ligament in the treatment of ankle injuries may be due to difficulties in diagnosis and lack of an effective method for repair. Most acute repair techniques address the superficial deltoid ligament with direct end-to-end repair, fixation through bone tunnels, or suture anchor repair of avulsion injuries. Deep deltoid ligament repair has been described using direct end-to-end repair with sutures, as well as by autograft and allograft tendon reconstruction utilizing various techniques. Newer tenodesis techniques have been described for late reconstruction of both deep and superficial components in patients with stage 4 adult acquired flatfoot deformity.
We describe a technique that provides anatomic ligament-to-bone repair of the superficial and deep bundles of the deltoid ligament while reducing the talus toward the medial malleolar facet of the tibiotalar joint with anchor-to-post reinforcement of the ligamentous repair. This technique may protect and allow the horizontally oriented fibers of the deep deltoid ligament to heal with the appropriate resting length while providing immediate stability of the construct.
PMCID: PMC3565408  PMID: 23576946
21.  Clinical and Radiological Evaluation after Arthroscopic Rotator Cuff Repair Using Suture Bridge Technique 
Clinics in Orthopedic Surgery  2013;5(4):306-313.
We retrospectively assessed the clinical outcomes and investigated risk factors influencing retear after arthroscopic suture bridge repair technique for rotator cuff tear through clinical assessment and magnetic resonance arthrography (MRA).
Between January 2008 and April 2011, sixty-two cases of full-thickness rotator cuff tear were treated with arthroscopic suture bridge repair technique and follow-up MRA were performed. The mean age was 56.1 years, and mean follow-up period was 27.4 months. Clinical and functional outcomes were assessed using range of motion, Korean shoulder score, Constant score, and UCLA score. Radiological outcome was evaluated with preoperative and follow-up MRA. Potential predictive factors that influenced cuff retear, such as age, gender, geometric patterns of tear, size of cuff tear, acromioplasty, fatty degeneration, atrophy of cuff muscle, retraction of supraspinatus, involved muscles of cuff and osteolysis around the suture anchor were evaluated.
Thirty cases (48.4%) revealed retear on MRA. In univariable analysis, retear was significantly more frequent in over 60 years age group (62.5%) than under 60 years age group (39.5%; p = 0.043), and also in medium to large-sized tear than small-sized tear (p = 0.003). There was significant difference in geometric pattern of tear (p = 0.015). In multivariable analysis, only age (p = 0.036) and size of tear (p = 0.030) revealed a significant difference. The mean active range of motion for forward flexion, abduction, external rotation at the side and internal rotation at the side were significantly improved at follow-up (p < 0.05). The mean Korean shoulder score, Constant score, and UCLA score increased significantly at follow-up (p < 0.01). The range of motion, Korean shoulder score, Constant score, and UCLA score did not differ significantly between the groups with retear and intact repairs (p > 0.05). The locations of retear were insertion site in 10 cases (33.3%) and musculotendinous junction in 20 cases (66.7%; p = 0.006).
Suture bridge repair technique for rotator cuff tear showed improved clinical results. Cuff integrity after repair did not affect clinical results. Age of over 60 years and size of cuff tear larger than 1 cm were factors influencing rotator cuff retear after arthroscopic suture bridge repair technique.
PMCID: PMC3858092  PMID: 24340151
Rotator cuff tear; Suture bridge technique; Retear; Magnetic resonance arthrography
22.  Evaluation of cartilage degeneration in a rat model of rotator cuff tear arthropathy 
Rotator cuff tears are the most common injury seen by shoulder surgeons. Many late stage rotator cuff tear patients develop glenohumeral osteoarthritis as a result of torn cuff tendons, termed cuff tear arthropathy. However, the mechanisms of cuff tear arthropathy have not been fully established. It has been hypothesized that a combination of synovial and mechanical factors contribute equally to the development of cuff tear arthropathy. The goal of this study was to assess the utility of this model in investigating cuff-tear arthropathy.
We utilized a rat model which accurately reflects rotator cuff muscle degradation after massive rotator cuff tears through either infraspinatus and supraspinatus tenotomy or suprascapular nerve transection. Using a Modified-Mankin Scoring System (MMS), we found significant glenohumeral cartilage damage following both rotator cuff tenotomy and suprascapular nerve transection after only 12 weeks.
Cartilage degeneration was similar between groups, and was present on both the humeral head and the glenoid. Denervation of the supraspinatus and infraspinatus muscles without opening the joint capsule caused cartilage degeneration similar to that found in the tendon transection group.
These results suggest that altered mechanical loading after rotator cuff tears is the primary factor in cartilage degeneration after rotator cuff tears. Clinically, understanding the process of cartilage degeneration after rotator cuff injury will help guide treatment decisions in the setting of rotator cuff tears.
Level of evidence
Basic Science Study, Animal Model
PMCID: PMC3806888  PMID: 23664745
massive rotator cuff tear; arthropathy; osteoarthritis; histology; articular cartilage
23.  Massive tears of the rotator cuff treated with a deltoid flap 
International Orthopaedics  2004;28(4):226-230.
We retrospectively reviewed the charts of 29 patients younger than 65 years at surgery treated with deltoid flap reconstruction for massive postero-superior rotator cuff tears. All tears involved supraspinatus and infraspinatus tendons and were associated with tendon stump retraction to the glenoid rim, a preservable long biceps tendon, and an intact subscapularis tendon. Mean follow-up was 10.5 years. Patient satisfaction rate was 89%. Mean global Constant score improved from 43 to 71.5 points, mean pain score from 6.3 to 13.2, mean anterior flexion from 100 to 157°, and force in elevation from 2.3 to 3 kg. Two thirds of patients had no humeral head migration. Of the 18 patients whose flap was examined by magnetic resonance imaging, 15 had no tear and 12 had a flap signal of muscle intensity; mean flap thickness was 5 mm. Pre-operative factors associated with poorer outcomes were upwards humeral head migration with a subacromial space smaller than 6 mm, presence of glenohumeral osteoarthritis, and supraspinatus amyotrophy greater than 40%. Deltoid flap reconstruction is a valid option in this patient population.
PMCID: PMC3456937  PMID: 15168082
24.  Surgical technique and clinical results for scapular allograft reconstruction following resection of scapular tumors 
Progress in developing effective surgical techniques, such as scapular allograft reconstruction, enhance shoulder stability and extremity function, in patients following scapular tumor resection.
Case details from seven patients who underwent scapular allograft reconstruction following scapular tumor resection were reviewed. A wide marginal resection (partial scapulectomy) was performed in all patients and all affected soft tissues were resected to achieve a clean surgical margin. The glenoid-resected and glenoid-saved reconstructions were performed in three and four patients, respectively. The residual host scapula were fixed to the size-matched scapular allografts with plates and screws. The rotator cuff was affected frequently and was mostly resected. The deltoid and articular capsule were infrequently involved, but reconstructed preferentially. The remaining muscles were reattached to the allografts.
The median follow-up was 26 months (range, 14–50 months). The average function scores were 24 points (80%) according to the International Society of Limb Salvage criteria. The range of active shoulder abduction and forward flexion motion were 40°–110° and 30°–90°, respectively. There was no difference between the glenoid-saved and glenoid-resected reconstructions in the total scores (mean, 24.5 points/81% versus 24 points/79%), but the glenoid-saved procedure was superior to the later in terms of abduction/flexion motion (mean, 72°/61° versus 55°/43°). During the study follow-up period, one patient died following a relapse, one patient lived despite of local recurrence, and five patients survived with no evidence of recurrence of the original cancer. Post-surgical complications such as shoulder dislocations, non-unions, and articular degeneration were not noted during this study period.
Scapular allograft reconstruction had a satisfactory functional, cosmetic, and oncological outcome in this case series. Preservation and reconstruction of the articular capsule and deltoid are proposed to be a prerequisite for using scapular allografts and rotator cuff reconstruction is recommended, although technically challenging to perform.
PMCID: PMC2670817  PMID: 19338652
25.  Shoulder pain 
BMJ Clinical Evidence  2010;2010:1107.
Shoulder pain is a common problem with an estimated prevalence of 4% to 26%. About 1% of adults aged over 45 years consult their GP with a new presentation of shoulder pain every year in the UK. The aetiology of shoulder pain is diverse and includes pathology originating from the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, and other soft tissues around the shoulder girdle. The most common source of shoulder pain is the rotator cuff, accounting for over two-thirds of cases.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatment, topical drug treatment, local injections, non-drug treatment, and surgical treatment? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 71 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, arthroscopic subacromial decompression, autologous whole blood injection, corticosteroids (oral, subacromial injection, or intra-articular injection), electrical stimulation, excision of distal clavicle, extracorporeal shock wave therapy, ice, laser treatment, manipulation under anaesthesia, suprascapular nerve block, non-steroidal anti-inflammatory drugs (oral, topical or intra-articular injection), opioid analgesics, paracetamol, physiotherapy (manual treatment, exercises), platelet-rich plasma injection, rotator cuff repair, shoulder arthroplasty, and ultrasound.
Key Points
Shoulder pain encompasses a diverse array of pathologies and can affect as many as one quarter of the population depending on age and risk factors. Shoulder pain may be due to problems with the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, or other soft tissues around the shoulder.
Rotator cuff problems are the most common source of shoulder pain, accounting for more than two-thirds of cases. Rotator cuff disorders are associated with musculoskeletal problems that affect the joints and muscles of the shoulder, cuff degeneration due to ageing and ischaemia, and overloading of the shoulder.
Frozen shoulder (adhesive capsulitis) accounts for 2% of cases of shoulder pain. Risk factors for frozen shoulder include female sex, older age, shoulder trauma and surgery, diabetes, and cardiovascular, cerebrovascular, and thyroid disease.
In many people, the cornerstone of treatment is achieving pain control to permit a return to normal functional use of the shoulder and encourage this with manual exercises. In people with acute post-traumatic tear, an early surgical option is warranted.
We don't know whether topical NSAIDs, oral corticosteroids, oral paracetamol, or opioid analgesics improve shoulder pain, although oral NSAIDs may be effective in the short term in people with acute tendonitis/subacromial bursitis. If pain control fails, the diagnosis should be reviewed and other interventions considered.
Physiotherapy may improve pain and function in people with mixed shoulder disorders compared with placebo.
Intra-articular corticosteroid injections may reduce pain in the short term compared with physiotherapy and placebo for people with frozen shoulder, but their benefit in the long term and when compared with local anaesthetic is unclear.
Platelet-rich plasma injections may improve the speed of recovery in terms of pain and function in people having open subacromial decompression for rotator cuff impingement, but further evidence is needed.
Acupuncture may not improve pain or function in people with rotator cuff impingement compared with placebo or ultrasound.
Extracorporeal shock wave therapy may improve pain in calcific tendonitis.
We found some evidence that suprascapular nerve block, laser treatment, and arthroscopic subacromial decompression may be effective in some people with shoulder pain.
We don't know whether autologous blood injections, intra-articular NSAID injections, subacromial corticosteroid injections, electrical stimulation, ice, ultrasound, rotator cuff repair, manipulation under anaesthesia, or shoulder arthroplasty are effective as we found insufficient evidence on their effects.
PMCID: PMC3217726  PMID: 21418673

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