The prevention and treatment of injuries to the shoulder in swimming

The biomechanics of swimming cause considerable stress on the shoulder joint which may be accentuated by improper stretching or training techniques. The rotator cuff, and particularly the supraspinatus tendon, is at risk in repetitive overhead stroke activity. Arthritis in the shoulder is primarily centered at the acromioclavicular joint; degeneration may occur as a result of overuse or leverage of the scapuloclavicular mechanism, or from motion related to upward pressure at the undersurface of the acromion due to subluxation or instability of the glenohumeral joint. Instability of the glenohumeral joint is a major problem which may occur in itself or in combination with rotator cuff tendinitis. The glenohumeral joint is stabilised superiorly by a posterior superior sling consisting of the long biceps tendon, the superior joint capsule, and the coracoacromial and coracohumeral ligaments. An anterior inferior sling mechanism consisting of the inferior glenohumeral ligament and subscapularis musculotendinous unit provides significant stability if uninjured. Fragments of labral tissue may mechanically wedge into the joint also leading to symptoms of subluxation. If the humeral head is wedged or allowed to slip out of joint due to capsular incompetency, secondary rotator cuff 'impingement' may occur; this is particularly difficult to manage. Prevention of injury is best accomplished through a programme of flexibility and strengthening avoiding overuse.     

Special shoulder problems in the throwing athlete: pathology, diagnosis, and nonoperative management

Shoulder problems in the overhead and throwing athlete can result in rotator cuff tendinitis. Biomechanically, there is a delicate balance between mobility and stability of the shoulder complex. Repetitive overhead stressful motion can lead to overuse tendinitis, subtle instability, labral changes, and eventual fiber failure of the rotator cuff. Secondary impingement symptoms are commonly present. An accurate diagnosis along with an early and aggressive rehabilitation program is essential in the treatment of these athletes.     

Spectrum of shoulder injuries in the baseball pitcher

This review describes a range of shoulder injuries experienced by baseball pitchers. It is estimated that more than 57% of pitchers suffer some form of shoulder injury during a playing season. Knowledge of the overhead throwing cycle is crucial for our understanding of these shoulder injuries. Baseball pitchers are prone to rotator cuff tears from tensile overload and impingement. Glenoid labrum degeneration or tears are also common, due to overuse syndrome (micro-instability), internal impingement and microtrauma. An understanding of the lesions involved in overhead throwing is crucial in baseball pitchers, as long-term disability can result from these injuries, sometimes with severe financial consequences to the player.     

MRI of the rotator cuff and internal derangement

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

Clinical tests for the diagnosis of rotator cuff disease

Several tests have been described to examine the shoulder. However, there is a lack of consensus on clinical assessment of patients with shoulder pain and suspected rotator cuff pathology. This review reports the diagnostic accuracy of clinical tests for rotator cuff pathology. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 21 clinical tests for rotator cuff pathology are reported from the available literature. Twenty studies investigated supraspinatus pathology, 12 infraspinatus pathology, and 9 subscapularis pathology. Most tests for rotator cuff pathology are inaccurate, and the recent literature shows that there is insufficient evidence to recommend 1 clinical test over another for diagnosis of rotator cuff pathology. Poor diagnostic accuracy of clinical tests for rotator cuff pathology may be related to the close relationships of structures in the shoulder, to a lack of understanding of anatomical basis of the tests, or to their lack of reproducibility.     

Imaging of shoulder pain in overhead throwing athletes

Overhead sports are widely practiced around the world and overhead athletes can present with pain and dysfunction in the throwing shoulder, generally due to degenerative changes secondary to overuse. Numerous etiologies can be taken into account, including rotator cuff and glenoid labrum tears, biceps pathologies, internal impingement, and gleno-humeral instability. In this setting, imaging plays a central role in early diagnosis, thus allowing for a prompt management, correct rehabilitation, and quick return to competition. This review is aimed to discuss the role of imaging to diagnose the most common types of overhead-related shoulder injuries.     

Surgical management of large rotator cuff tears combined with instability in elite rugby football players

Large rotator cuff tears are extremely uncommon in young people and when they occur they may be associated with shoulder instability. This paper reports on a series of six elite rugby union and rugby league footballers who presented with shoulder instability and large rotator cuff tears. They were treated with a two stage procedure: an open rotator cuff repair followed by an open shoulder stabilisation some 10 weeks later. All had successful outcomes. The paper also highlights the risk of tearing the rotator cuff when a patient continues to play contact sport with an untreated unstable shoulder.     

Diagnosis of tears in rotator-cuff-injuries

Pathology of the rotator cuff is the cause of most common problems at the shoulder joint. Acute injuries are not as frequent as chronic cuff disease, but often they aggravate inflammatory or degenerative tendon alterations, even if they are of minor severity. Traumatic rotator cuff tears predominantly affect the supraspinatus tendon or the rotator interval. The subscapularis tendon is involved in anterior dislocations of the glenohumeral joint or in direct trauma. Plain film radiography still remains the base of all further imaging studies. If only full-thickness tears must be ruled out, double-contrast arthrography and ultrasound are acceptable imaging modalities. However, the former has a drawback in being invasive and does not detect partial tears at the bursal site of the cuff or rotator cuff tendinopathy, whereas the latter heavily depends on the experience of the radiologist and is restricted to the rotator cuff. Nowadays the most comprehensive imaging method is magnetic resonance (MR) imaging. MR imaging enables the detection or exclusion of complete rotator cuff tears with a reasonable accuracy and is also suitable to diagnose further pathologies of the shoulder joint. MR arthrography is valuable in the detection of subtle anatomic details and further improves the differentiation of rotator cuff diseases. Although in comparison MR imaging is still the most expensive imaging method, its high negative predictive value for the diagnosis of complete rotator cuff tears and its reliability evaluating different shoulder joint pathologies make it the preferred imaging modality.     

Rotator cuff contusions of the shoulder in professional football players: epidemiology and magnetic resonance imaging findings

BACKGROUND: No published reports have studied the epidemiology and magnetic resonance imaging findings associated with rotator cuff contusions of the shoulder in professional football players. PURPOSE: To determine a single professional football team's incidence, treatment, and magnetic resonance imaging appearance of players sustaining rotator cuff contusions of the shoulder. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From 1999 to 2005, a North American professional football team's injury records were retrospectively reviewed for athletes who had sustained a rotator cuff contusion of the shoulder during in-season participation. Those patients who had magnetic resonance imaging of the shoulder with a 1.5-Tesla magnet were reviewed by a musculoskeletal radiologist and graded according to the appearance and severity of clinical injury. RESULTS: Twenty-six players had a rotator cuff contusion. There was an average of 5.5 rotator cuff contusions per season (47% of all shoulder injuries). The predominant mechanism of injury was a direct blow in 70.3%. Magnetic resonance imaging findings included peritendon edema at the myotendinous junction, critical zone tendon edema, and subentheseal bone bruises. Treatment consisted of a protocol involving modalities and cuff rehabilitation in all patients. Six patients had persistent pain and weakness for a minimum of 3 days and were given a subacromial corticosteroid injection. Overall, 3 patients (11.4%) required later surgical treatment on the shoulder. CONCLUSION: Rotator cuff contusions accounted for nearly half of all shoulder injuries in the football players in this study. Magnetic resonance imaging is an extremely useful tool in determining severity of injury and integrity of the rotator cuff. The majority of athletes are able to return to sports with conservative treatment; a minority of shoulders might progress to more severe injuries such as rotator cuff tears.     

A systematic review of the reverse shoulder replacement in rotator cuff arthropathy, rotator cuff tears, and rheumatoid arthritis

The reverse shoulder arthroplasty prosthesis was originally designed for rotator cuff arthropathy, and provided good results. Over time, the indications have expanded to include, among others, irreparable rotator cuff tears and rheumatoid arthritis, and the results have become more variable. There are also fundamental differences in the designs of the original Delta III prostheses and the later developed reverse shoulder prosthesis, and many studies that provide the results in reverse shoulder arthroplasties do not consider these 2 prostheses separately. In this systematic review, we analyze the clinical outcomes of the reverse shoulder arthroplasty in rotator cuff arthropathy, rotator cuff tears without arthropathy, and rheumatoid arthritis. We also analyze the results of the 2 prostheses separately to provide a more accurate comparison.     

Arthroscopic rotator cuff repair

The use of the arthroscope to address shoulder pathology is continuously evolving. Many aspects of shoulder arthroscopy are readily accepted and used by orthopedic surgeons, but some procedures can be technically difficult. Arthroscopic rotator cuff repair has traditionally involved the use of cumbersome knot tying techniques, deterring many surgeons from using this technique. Although open and mini-open rotator cuff repair is commonly used with predictable results, there still remains inherent morbidity to any open technique. This article will outline a technique that avoids knot tying and suture management in arthroscopic rotator cuff repair. Although the indications are evolving, arthroscopic rotator cuff repair allows predictable results with excellent pain relief and return to function.     

MR imaging of the shoulder. Impingement and instability-related abnormalities

In addition to the case history and the clinical examination, MR imaging has an important role in the diagnosis and differential diagnosis of numerous shoulder abnormalities and in the investigation of chronic shoulder pain. Important indications for MR imaging are any conditions or symptoms making assessment of the rotator cuff and the labrocapsular complex necessary. Assessment of the rotator cuff muscles, in particular, is crucial. The value of MR arthrography, which is still controversial, is discussed. The greatest potential benefit of MR arthrography is the accurate evaluation of subtle rotator cuff abnormalities and shoulder instability-related lesions, and the assessment of pathologic conditions of the long biceps tendon. This paper describes the most common pathologic findings of the shoulder joint and describes how the relevant findings are reported and quantified for the orthopaedic shoulder surgeon.     

Ultrasound measurement of rotator cuff thickness and acromio-humeral distance in the diagnosis of subacromial impingement syndrome of the shoulder

The usefulness of ultrasound measurements in the diagnosis of the subacromial impingement syndrome of the shoulder was evaluated. Fifty-seven patients with unilateral symptoms of the impingement syndrome underwent ultrasound examination of both shoulder joints, which included assessment of rotator cuff integrity, measurement of rotator cuff thickness and the distance between the infero-lateral edge of acromion and the apex of the greater tuberosity of humerus (AGT distance) in the standard ultrasonographic positions. As a control group, 36 volunteers (72 shoulders) with no history of shoulder pain were examined sonographically. Ultrasonographic assessment of humeral head elevation, measured as the AGT distance, proved to be useful in establishing the diagnosis of the subacromial impingement syndrome of the shoulder. A difference in rotator cuff thickness of more than 1.1 mm and a difference in the AGT distance of more than 2.1 mm between both shoulder joints may reflect dysfunction of rotator cuff muscles.     

Biomechanical factors in rotator cuff pathology

The rotator cuff provides dynamic stability and is critical to normal shoulder function. Forces generated by the rotator cuff facilitate the motions involved in activities of daily living and the more demanding movements of athletics and manual labor. Injury and pathology of the rotator cuff are common and the unique anatomical and biomechanical characteristics of the cuff contribute to the etiology of its injury. This review provides a biomechanical and anatomic context to understanding normal rotator cuff function and summarizes recent work describing biomechanical implications of cuff pathology.     

Conservative management of rotator cuff tear

Ranking among the most prevalent of shoulder disorders, lesions involving shoulder rotator cuff strike million of patients in the United States at different points in their lives. Despite the fact that rotator cuff disease is a very common cause of pain and disability of the upper arm, a high proportion of patients is asymptomatic and unaware of performing daily living activities despite of a shoulder lesion. Given these drawbacks, surgeons are trying exploring whether conservative treatment is a viable option for the management of these injuries. This study presents a rationale to consider nonoperative treatment an effective option when dealing with patients with rotator cuff tears.     

Magnetresonanztomographie der Schulter

In addition to the case history and the clinical examination, MR imaging has an important role in the diagnosis and differential diagnosis of numerous shoulder abnormalities and in the investigation of chronic shoulder pain. Important indications for MR imaging are any conditions or symptoms making assessment of the rotator cuff and the labrocapsular complex necessary. Assessment of the rotator cuff muscles, in particular, is crucial. The value of MR arthrography, which is still controversial, is discussed. The greatest potential benefit of MR arthrography is the accurate evaluation of subtle rotator cuff abnormalities and shoulder instability-related lesions, and the assessment of pathologic conditions of the long biceps tendon. This paper describes the most common pathologic findings of the shoulder joint and describes how the relevant findings are reported and quantified for the orthopaedic shoulder surgeon.     

Sonographic detection of rotator cuff tears

Thirty-nine consecutive patients referred for shoulder arthrography underwent shoulder sonography to determine the ability of sonography to detect rotator cuff tears. Fifteen patients had arthrographically proven rotator cuff tears. Of these, 14 were detected by sonography, for a sensitivity of 93%. The three sonographic criteria indicative of rotator cuff tear were (1) discontinuity in the normal homogeneous echogenicity of the rotator cuff; (2) replacement of the normal homogeneous echogenicity by a central echogenic band; and (3) nonvisualization of the cuff. Twenty patients had normal sonographic examinations, 19 of which were normal by arthrography. Therefore, the predictive value of a negative sonogram was 95%. On the basis of these findings, sonography can provide a noninvasive means of screening patients with suspected rotator cuff tears.     

Magnetic resonance imaging of the rotator cuff muscles after baseball pitching

AIM: The purposes of present study were to investigate quantitatively using functional MR imaging the effect of a series of throwing activities on rotator cuff muscles and to compare the effect of pitching with that of all-out shoulder external rotator exercise as the targeted external rotator muscle group (the infraspinatus and the teres minor). METHODS: Experimental design: MRI measurements after 135 baseball pitches or all-out shoulder external rotator exercise (concentric mode) in each subject's nondominant shoulder. Participants: 6 amateur baseball pitchers. Measures: serial T2-weighted images of rotator cuff muscles were obtained before pitching (or shoulder exercise) and immediately, 30, 60 min, 24, 48, 96 hrs after pitching (or shoulder exercise). T2 relaxation times (T2) at each measurement time were calculated for the rotator cuff muscles. RESULTS: Both the supraspinatus and the external rotator muscle group showed significant T2 elevations until 96 hrs after pitching. The subscapularis also showed significantly increased T2 until postpitching 48 hrs. On the other hand, a significant T2 elevation continued until 60 min after shoulder exercise, but thereafter returned towards the value at rest over the next 24 hrs. CONCLUSION: Long lasting T2 elevations in rotator cuff muscles would be associated with an increase in each intramuscular water content, and may be attributed to the muscle damage that resulted from eccentric contraction during pitching. This information should serve as a useful complement to shoulder injury prevention for baseball pitchers.     

Sonography of the Shoulder

A great amount of work in musculoskeletal sonography has focused on evaluation of the shoulder and rotator cuff. This is primarily due to the fact that the shoulder is a common site of symptomatology and clinical evaluation is difficult. Even though sonography of the rotator cuff is more difficult than other large tendons, there has been constant incentive to develop and refine shoulder sonography. In the past five years there have been dramatic improvements in high resolution transducers, as well as advances in our understanding of the technique of shoulder sonography and more widespread agreement of the findings seen with rotator cuff tears. All of these factors have contributed to making the exam easier to perform and interpret than in the past. Ultrasound has now evolved into a mature modality for evaluating rotator cuff tears with expected sensitivities of better than 90%.