Kinesthetic sense of the shoulder in patients with impingement syndrome

A proprioceptive deficit is an important determinant of disability in various shoulder disorders, such as instability and osteoarthrosis. In 15 patients with impingement syndrome stage II (Neer 1983), who were treated by arthroscopic subacromial decompression, we measured movement sense by determining threshold levels for the perception of motion of the shoulder. The patients were placed in a specially designed chair allowing continuous passive motion of the shoulder joint, while avoiding cutaneous, auditory and visual stimuli. To assess movement detection thresholds, passive abduction movements of the shoulder were performed at a starting angle of 60 degrees, an amplitude of 10 degrees and an angular velocity of 1.3 degrees/s. Before surgery, all patients had higher threshold levels for the perception of motion in their affected shoulders then in the other side. After decompression, proprioception had improved on the decompressed side, but was unchanged on the other side.     

Surgical exposure of the stiff knee

A proprioceptive deficit is an important determinant of disability in various shoulder disorders, such as instability and osteoarthrosis. In 15 patients with impingement syndrome stage II (Neer 1983), who were treated by arthroscopic subacromial decompression, we measured movement sense by determining threshold levels for the perception of motion of the shoulder. The patients were placed in a specially designed chair allowing continuous passive motion of the shoulder joint, while avoiding cutaneous, auditory and visual stimuli. To assess movement detection thresholds, passive abduction movements of the shoulder were performed at a starting angle of 60°, an amplitude of 10° and an angular velocity of 1.3°/s. Before surgery, all patients had higher threshold levels for the perception of motion in their affected shoulders then in the other side. After decompression, proprioception had improved on the decompressed side, but was unchanged on the other side.     

The reproducibility of measurement of shoulder movement

To study the reproducibility of the measurement of shoulder movement, we have examined a series of 64 patients with and without shoulder problems, measuring active elevation, abduction, and external rotation in adduction using an inclinometer. The difference within which readings by different observers were expected to lie for 95% of the pairs of observations ranged from 24° to 33° for different movements in asymptomatic shoulders and from 24° to 41° in those with unilateral shoulder symptoms awaiting surgery.     

The effect of instability and subsequent anterior shoulder repair on proprioceptive ability

Proprioceptive ability was prospectively evaluated in patients with recurrent traumatic anterior instability who subsequently underwent anterior shoulder repair. Thirty consecutive patients were evaluated for passive position sense and detection of motion with the shoulder in flexion, abduction, and external rotation 1 week before surgery. They were then retested at 6 and 12 months postoperatively. A significant deficit in proprioception was found when the unstable side was compared with the uninvolved side before surgery. Six months after surgical repair, position sense showed an improvement of approximately 50% but was still found to be significantly different on the involved side; detection of motion was no longer significantly different from the uninvolved shoulder. One year after open anterior shoulder repair, both position sense and detection of motion were equivalent to those of the uninvolved shoulder.     

Neural and muscular electric activity in the cat's knee: Changes when the anterior cruciate ligament is transected

We studied the response of the normal and unstable knee to passive motion and anterior tibial displacement in the cat. 6 cats were anesthetized and the deep level of anesthesia was controlled by electroencephalograms. We recorded electric activity in the articular nerves (posterior PAN and medial MAN) and periarticular muscles (quadriceps and hamstring), while performing passive flexion, extension, internal and external rotation. We then produced anterior displacement of the tibia at 30° and 90° of flexion, as in the Lachman and the anterior drawer maneuvers. The anterior cruciate ligament was surgically sectioned and the same series of passive displacements was performed. We observed statistically significant increased activity in the MAN, the PAN and the quadriceps muscle during knee flexion, in the MAN during extension, and in the PAN and hamstring during external rotation with the knee 90° flexed. Anterior cruciate transection caused anterior displacement of the tibia during stress. This produced a significant increase in the MAN activity and a significant decrease in the hamstring electric activity at 30° and 90° of flexion, as in Lachman and anterior drawer maneuvers. We conclude that electric activity in the articular nerves and periarticular muscles, in response to passive motion and anterior tibial displacement, is altered in the cat's knee after anterior cruciate transection. This suggests that various patterns of periarticular muscle reaction in the anterior cruciate-deficient knee may be related to the unconscious perception of abnormal motion.     

Proprioception in people with anterior cruciate ligament-deficient knees: comparison of symptomatic and asymptomatic patients

STUDY DESIGN: Nonrandomized prospective study. OBJECTIVE: To evaluate proprioception in 2 groups of patients with anterior cruciate ligament (ACL) deficiency who had different severity of symptoms. BACKGROUND: Defective proprioception has previously been found in patients with ACL-deficient knees. It has been suggested that sensory receptors of the ACL and other knee joint ligaments contribute to proprioception and knee joint function and stability. METHODS AND MEASURES: A total of 17 patients with ACL deficiency (mean [SD] age, 28.8 +/- 5.6 years; range, 22-39 years) with few, if any, symptoms were compared with 20 patients with ACL deficiency (mean [SD] age, 26.6 +/- 6.1 years; range, 18-39 years) having instability and episodes of giving way. The groups were compared with each other and with an age-matched reference group of 19 nonimpaired subjects. Their mean (SD) age was 25.6 +/- 3.7 years (range, 20-37 years). Three tests of proprioception were used: threshold to detection of passive motion from 2 starting positions (20 degrees and 40 degrees of knee flexion) toward flexion and extension, active reproduction of a 30 degrees passive angle change, and visual reproduction of a 30 degrees passive angle change. The Wilcoxon rank sum test was used for between-group comparisons. RESULTS: Symptomatic patients had higher threshold to detection of passive motion in their injured side in the flexion trial from 20 degrees (median of 1.5 degrees vs median of 0.5 degree) and in the extension trial from 40 degrees (median of 1.0 degree vs median of 0.5 degree) than the asymptomatic patients. No differences were found in the other threshold tests, active or visual reproduction tests. CONCLUSIONS: Patients with severe symptoms related to ACL deficiency were found to have inferior proprioceptive ability in some measurements compared with patients with a good knee function. The findings indicate that proprioceptive deficits might influence the outcome of an ACL injury treated nonoperatively.     

Trapezius transfer for shoulder paralysis: 6 patients with brachial plexus injuries followed for 1 year

We transferred the trapezius with its bone insertion to the proximal humerus in 6 patients for treatment of a paralytic shoulder secondary to traumatic lesions of the brachial plexus. After 1 year, the shoulder abduction was improved from average 13° (0°-30°) preoperatively to 76° (50°-100°) postoperatively, and the shoulder flexion from 18° (0°-40°) to 78° (45°-110°) postoperatively. All the patients were satisfied with the outcome.We consider that transfer of the trapezius in a paralytic shoulder after brachial plexus injury gives a better outcome than shoulder fusion.     

Detailed analysis of proprioception in normal and ACL-deficient knees.

We assessed proprioception using threshold levels for the perception of knee movement at slow angular velocities (0.1 degrees/s to 0.85 degrees/s) in 20 patients with unilateral tears of the anterior cruciate ligament (ACL) and 15 age-related control subjects. Failure to detect movement was also analysed. The threshold levels of detection did not differ between the damaged and undamaged knees in the patients or between the patients and the control group. Failure to appreciate movement, however, was significantly greater in knees with ACL loss compared with the undamaged knees of patients and the control group. Our findings show a proprioceptive deficit in the absence of the ACL. Measurements of threshold levels of detection of passive movement alone are not suitable for the evaluation of proprioceptive loss in ACL deficiency; assessment of failure to appreciate movement is essential.     

Shoulder joint stability after arthroscopic subacromial decompression

In 55 patients with type I or type II impingement lesions we performed arthroscopic subacromial decompression. Fifty-two patients are followed up 1 year postoperatively. In all patients the condition of the affected shoulder before and after decompression was documented using a 100-point shoulder score (pain on activity, 15 points; pain without activity, 15 points; function, 20 points; weight lifting, 10 points; muscle strength, 15 points; range of motion, 25 points). At follow-up we also documented the extent of passive inferior shift of the humeral head by ultrasound. The mean score preoperatively was 60.9 (± 13.8). Postoperatively there was a significant increase to 84.7 (± 12.5). The average postoperative hospital stay was 8.8 days (± 2.1). In 12 patients (23%) the postoperative score was less than 85 points, and in these the treatment was considered to have failed. Comparison of these patients as a group with those in whom the treatment was successful revealed no difference in age, a small but not significant difference in the preoperative duration of shoulder complaints, and no difference in the postoperative length of stay in hospital. However, there was a significant difference in the extent of passive inferior shift of the humeral head: in the failure group the mean inferior shift was 4.6 ± 1.9 mm, while in the other patients the shift was only 2.7 ± 1.0 mm. This difference was statistically highly significant. There was a statistical highly significant negative Pearson correlation coefficient of –5.56 between postoperative score and inferior shift of the humeral head. We conclude that patients with subacromial pathology and hypermobile glenohumeral joints may not be good candidates for subacromial decompression.     

Surgical peri- and postoperative plexus anesthesia in subacromial decompression of the shoulder

AIM: The aim of the present investigation was to check the peri- and postoperative plexus anesthesia on early functional outcome and postoperative analgetic consumption during subacromialen decompression until the date of discharge. METHODS: 50 patients in the period 01.01.1997 to 01.10.1998 treated by an arthroscopic or open subacromial decompression of the shoulder were registered. Pre- and postoperative functional movement and postoperative analgetic consumption within the first 12 days after the operation were compared according to the procedure used. RESULTS: The peri- and postoperative plexus anesthesia had a positive influence to early functional outcome as well as on the analgetic consumption. The results are shown in the group of arthroscopic (18) surgery and in the group of the patients operated in an open (32) technique. The patients with plexus anesthesia showed a better functional movement of the shoulder directly postoperatively and a lower consumption analgetic drags. At the time of discharge we found no significant differences between the subjects in both groups. CONCLUSION: The investigation shows that peri- and postoperative plexus anesthesia has no positive influence on the early functional outcome after subacromial decompression of the shoulder.     

Panclavicular ankylosis in pustulotic arthroosteitis. A case report

A 54-year-old man who had palmoplantar pustulosis showed bilateral, complete osseous fusion of the sternoclavicular and acromioclavicular joints. No significant abnormality was seen in the glenohumeral joint. The left clavicle had a nonunion develop, whereas the right did not. The elevation of the right shoulder was limited to 100 degrees in active and passive measurements. The total external rotation and internal rotation at the side was 135 degrees. This decreased to 90 degrees at 60 degrees elevation and to 10 degrees at maximum (100 degrees) elevation. Based on the kinematic data on normal shoulders, it was thought that the ankylosis of both ends of the clavicle held the scapula unrotated during the arm movement so that, at the arm to trunk angle of 100 degrees, the position of the humerus relative to the scapula was equivalent to that of a normal shoulder in complete elevation. The current case provided an extremely rare clinical setting where shoulder mobility depended only on glenohumeral motion as a result of the complete loss of scapulothoracic motion.     

Postoperative pain management for arthroscopic shoulder surgery: interscalene block versus patient-controlled infusion of 0.25% bupivicaine

We compared an interscalene block with a patient-controlled regional anesthesia device (Pain Care 2000; Breg, Inc, Vista, Calif) for pain management after outpatient arthroscopic shoulder surgery (subacromial decompression as principal procedure). The 41 patients in this prospective study were randomized to receive either the block or the device. During the postoperative period, all patients in both groups received standardized oral medications and continuous cold therapy and used continuous passive motion machines. Patients were given diaries and instruction in making entries upon waking and before retiring on postoperative days 1, 2, 3, 5, and 10. Data collected were number of pain medications used each day; number of nighttime awakenings; and subjective pain, activity, and quality-of-life levels rated on a visual analog scale. All data were statistically analyzed with the Mann-Whitney test. Compared with patients using the block, patients using the device awoke significantly fewer times the first night after surgery (P = .023), were significantly more active during postoperative days 1 and 2 (Ps = .018, .042), and took significantly fewer pain medications on postoperative day 2 (P = .034). On all other measures, results were equivalent or were better with the device, though these findings were not statistically significant. Patient-controlled subacromial infusion of bupivicaine is an effective alternative to interscalene block for outpatient pain management after arthroscopic shoulder surgery.     

Bipolar shoulder arthroplasty for rotator cuff arthropathy

Between July 1991 and February 1995, 33 patients underwent bipolar shoulder arthroplasty for painful rotator cuff arthropathy of the shoulder. Twenty-two of these patients have been followed for an average of 28 months (range 24 to 48 months) and comprised the study group. All patients had massive, irreparable rotator cuff tears and presented with preserved passive motion, good deltoid function, and obliterated glenohumeral joint surfaces. Function and comfort were dramatically improved in all patients, with an average increase in active forward elevation of 29° and a gain in active external rotation of 39°. There was one complication requiring reoperation at 4 years. Utilizing the UCLA and Swanson scoring systems, all patients were rated fair or better.     

The Kapandji procedure for post-traumatic problems

The Kapandji procedure was performed on 14 patients who presented with chronic pain at the distal radioulnar joint, limited forearm rotation or poor grip after an injury involving the distal radioulnar joint. Ten patients were able to resume their original occupation and leisure activities. Some complained of mild aching after heavy use. Postoperatively, grip strength on the affected side was, on average, 84 per cent that of the opposite side. Forearm rotation in the affected arm averaged 129 ° before operation and 170 ° afterwards, compared with 171 ° on the normal side, while wrist flexion-extension averaged 129 ° preoperatively, 126 ° postoperatively and 148 ° on the normal side.

Four patients had less satisfactory results because of pain and a feeling of insecurity due to an unstable proximal ulna. However, two of these had severe residual problems in relation to the initial forearm component of the injury, the symptoms from which were difficult to separate from the distal radioulnar injury.

Although the Kapandji procedure can yield excellent results, it is difficult to predict which patients will suffer from an unstable ulna.     

Association between Shoulder Range of Motion and Pain Catastrophizing Scale in Breast Cancer Patients after Surgery

BackgroundProlonged survival period as a result of early diagnosis and treatment in breast cancer has increased the importance of postoperative morbidities. The aim of the present study was to investigate the association of pain ca­tastrophizing with shoulder pain in patients with decreased shoulder range of motion in the postoperative period.Patients and MethodsThe present study included 53 patients who underwent surgery due to breast cancer. Patients who had bilateral mastectomy, distant metastases, cervical-cranial originated lesions, patients with problems involving one of the shoulders or upper extremities before the operation, and patients with cognitive impairment, heart failure, or low albumin levels (liver parenchyma disease or renal failure) were excluded. Shoulder range of motion was measured in the postoperative period, and two study groups were established: one with a limited shoulder range of motion level and the other with a normal level. Effects of pain catastrophizing and shoulder pain severity on shoulder range of motion limitation were compared between the two groups.ResultsThe average age of 53 female patients who had breast surgery was 52.3 ± 10.5 years. In the group with limited shoulder range of motion, the median pain catastrophizing scale value was 27 (range 5–32) and the shoulder pain severity score was 4 (range 0–8), while in the group with normal shoulder range of motion these values were 11 (range 3–39) and 2 (range 0–6), respectively (p < 0.05). In addition, it was found that factors such as surgical treatment modality and postoperative radiotherapy did not significantly affect shoulder range of motion limitation.ConclusionDetermining the pain catastrophizing scale of patients and controlling pain in the early postoperative period could have positive effects on shoulder range of motion.     

Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment

Seventeen patients who had recalcitrant chronic adhesive capsulitis were operated on between 1979 and 1986 and were followed for an average of 6.8 years. At operation, the major cause of the restricted glenohumeral movement was found to be contracture of the coracohumeral ligament and rotator interval. Release of the contracted structures relieved pain and restored motion of the shoulder in all patients. Histological study showed fibrosis, hyalinization, and fibrinoid degeneration in the contracted connective tissues, as well as fibrosis of the subsynovial tissue and an absence of the synovial cell layer on the joint side of the rotator interval. The contracture of the coracohumeral ligament and rotator interval appears to be the main lesion in chronic adhesive capsulitis. Resection of these structures, combined with appropriate exercise, will relieve pain and restore motion to the shoulder.     

Satisfied patients after shoulder arthrodesis for brachial plexus lesions even after 20 years of follow-up

Purpose

Patients with an upper brachial plexus lesion can suffer from dysfunction, joint deformities and instability of the shoulder. The goal of this study was to determine pain, shoulder function, patient satisfaction and muscle strength in shoulder arthrodesis in patients with an upper brachial plexus lesion more than 15 years after surgery.

Methods

We retrospectively studied 12 patients with a brachial plexus lesion of mean age 46 years (27–61). At a mean of 19.8 years (15.4–30.3) after shoulder arthrodesis, patient-reported outcome measures (PROMs), range of motion (e.g., active and passive), patient satisfaction, strength of the affected and non-affected side (e.g., maximum isometric strength in Newton in forward and retroflexion, ab- and adduction, internal and external rotation) and position of fusion were obtained. PROMS consisted of the Visual Analogue Scale (VAS; 0–100, 0 being painless) for pain and the Disabilities of the Arm, Shoulder and Hand Score (DASH; 0–100, 0 being the best score) for function.

Results

At latest follow-up, the median VAS pain score was 49 (0–96) and 0 for, respectively, the affected and unaffected side. The DASH was 15 (8–46), meaning a reasonable to good function of the upper extremity. Active and passive retroflexion was significantly different (p = 0.028). All subjects stated that in the same situation they would undergo a shoulder arthrodesis again. The unaffected side was significantly stronger in every direction. Arthrodesis showed position of fusion of 31° (12–70) abduction, 20° (10–50) forward flexion and 22° (? 14 to 58) internal rotation. The unaffected side was significantly (p ≤ 0.05) stronger in every movement direction.

Conclusion

At a mean of 20 years after shoulder arthrodesis, patients with an upper brachial plexus lesion are still satisfied with a good to moderate functional improvement.

Level of evidence III

A retrospective cohort study.

     

An Arthroscopic Technique for Treating Patients With Frozen Shoulder

Summary: Forty-three patients with a diagnosis of primary or secondary frozen shoulder who had symptoms for an average of 12 months and failed conservative treatment of at least 12 weeks of physical therapy, were treated with an arthrosopic capsular release. Oon completion of standard shoulder arthroscopy, intra-articular cautery was used to completely divide the anterior-inferior capsule, the intra-articular portion of the subscapularis tendon, and the middle glenohumeral, the superior glenohumeral, and the coracohumeral ligaments. The subacromial space was inspected in all patients. Eighteen patients had extensive subacromial fibrosis that required debridement. Subacromial decompression was reserved for patients with evidence of an acromial spur seen at the time of arthroscopy. Postoperatively, all patients showed substantial gains in shoulder range of motion, as well as diminished shoulder pain. Thirty-five patients completed a telephone survey at an average of 22 months after surgery. The average modified shoulder score was 19 (scale, 13 to 65), with 83% of patients indicating that their shoulder was normal or caused only mild symptoms. In conclusion, the authors believe that arthroscopic capsular release is an effective and safe alternative to manipulation in patients with a recalcitrant frozen shoulder.0749-8063/99/1501-1667$3.00/0     

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 Points

• Local 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.

Key Words: Cryotherapy, muscle stretching exercise, shoulder