The reliability, validity, and methodologic quality of measurements used to quantify posterior shoulder tightness: a systematic review of the literature with meta-analysis.

HYPOTHESIS AND BACKGROUND: Posterior shoulder tightness (PST) has been linked to numerous shoulder pathologies in both the general and athletic populations. Several methods for documenting PST have been described in the literature, which may lend to variability in clinical practice and research. The purpose of this study was to perform a systematic review with meta-analysis to investigate the reliability, validity, and methodologic quality of methods used to quantify PST. METHODS: Relevant studies were assessed for inclusion, and selected studies were identified from the PubMed, Embase, Cochrane, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. Data were extracted from the selected studies and underwent methodologic quality assessment and meta-analysis. RESULTS: The search resulted in 1006 studies identified, with 18 ultimately retained. Intrarater reliability was reported in 12 studies with a summary intraclass correlation coefficient of 0.93 (95% confidence interval, 0.90-0.95), whereas inter-rater reliability was reported in 6 studies with a summary intraclass correlation coefficient of 0.89 (95% confidence interval, 0.80-0.94). Validity was reported in 10 studies, all using internal rotation as the convergent standard, and was found to be significant in all but 1 study. CONCLUSION: Current methods used to quantify PST have good reliability but are primarily limited to measures of horizontal adduction of the glenohumeral joint with scapular stabilization. Limitations in using a single measurement technique exist particularly as there may be multiple contributing factors to PST. A more comprehensive approach for quantifying PST is necessary, and suggested components include a cluster of techniques composed of horizontal adduction, internal rotation, and total glenohumeral joint range of motion.

The efficacy of stretching exercises to reduce posterior shoulder tightness acutely in the postoperative population: a single blinded randomized controlled trial.

BACKGROUND: Posterior shoulder tightness (PST) is a postoperative complication leading to pain, impaired mobility, and reduced function. Despite the potential morbidity associated with PST, no studies have investigated the efficacy of shoulder-stretching methods in the postsurgical population. The purpose of this study was to determine the short-term efficacy of two stretches designed to reduce PST. METHODS: The study enrolled 63 patients [mean age 51 (12) years, height 173.7 (3.6) cm, body mass 88.2 (17.9) kg]. The study was a single-blinded randomized control trial in which patients who had arthroscopic shoulder surgery were assigned to one of three groups: [(horizontal adduction stretch (n = 21), supine sleeper (n = 21), or control (n = 21)]. Dependent variables included measurements of internal rotation mobility, sidelying PST, pain, and the QuickDASH. Following the physical therapy (PT) initial evaluation, subjects were instructed to perform the allocated intervention twice daily until their first follow-up appointment 48-72 h following the initial PT visit. RESULTS: Between group analyses of dependent variables revealed significant differences within PST measurements (p = 0.005) (eta squared = 0.14) taken at baseline and follow-up (48-72 h) favoring horizontal adduction stretching. Post-hoc testing demonstrated superiority of horizontal adduction stretching over both the supine sleeper group (p = 0.01) and control (p = 0.002). DISCUSSION AND CONCLUSION: The horizontal adduction stretch is more effective at reducing acute PST in the postoperative shoulder population when compared to the supine sleeper stretch and no stretch at all. Knowledge of efficacious stretching methods may serve to reduce the potential morbidity associated with postoperative stiffness.

Assessments of Fatty Infiltration and Muscle Atrophy From a Single Magnetic Resonance Image Slice Are Not Predictive of 3-Dimensional Measurements.

PURPOSE: To (1) determine whether standard clinical muscle fatty infiltration and atrophy assessment techniques using a single image slice for patients with a rotator cuff tear (RCT) are correlated with 3-dimensional measures in older individuals (60+ years) and (2) to determine whether age-associated changes to muscle morphology and strength are compounded by an RCT. METHODS: Twenty older individuals were studied: 10 with an RCT of the supraspinatus (5 men and 5 women) and 10 matched controls. Clinical imaging assessments (Goutallier and Fuchs scores and cross-sectional area ratio) were performed for participants with RCTs. Three-dimensional measurements of rotator cuff muscle and fat tissues were obtained for all participants using magnetic resonance imaging (MRI). Isometric joint moment was measured at the shoulder. RESULTS: There were no significant associations between single-image assessments and 3-dimensional measurements of fatty infiltration for the supraspinatus and infraspinatus muscles. Compared with controls, participants with RCTs had significantly increased percentages of fatty infiltration for each rotator cuff muscle (all P ≤ .023); reduced whole muscle volume for the supraspinatus, infraspinatus, and subscapularis muscles (all P ≤ .038); and reduced fat-free muscle volume for the supraspinatus, infraspinatus, and subscapularis muscles (all P ≤ .027). Only the teres minor (P = .017) fatty infiltration volume was significantly greater for participants with RCTs. Adduction, flexion, and external rotation strength (all P ≤ .021) were significantly reduced for participants with RCTs, and muscle volume was a significant predictor of strength for all comparisons. CONCLUSIONS: Clinical scores using a single image slice do not represent 3-dimensional muscle measurements. Efficient methods are needed to more effectively capture 3-dimensional information for clinical applications. Participants with RCTs had increased fatty infiltration percentages that were likely driven by muscle atrophy rather than increased fat volume. The significant association of muscle volume with strength production suggests that treatments to preserve muscle volume should be pursued for older patients with RCTs. LEVEL OF EVIDENCE: Level II, diagnostic study, with development of diagnostic criteria on the basis of consecutive patients with universally applied reference gold standard.

Combining orthopedic special tests to improve diagnosis of shoulder pathology.

The use of orthopedic special tests (OSTs) to diagnose shoulder pathology via the clinical examination is standard in clinical practice. There is a great deal of research on special tests but much of the research is of a lower quality implying that the metrics from that research, sensitivity, specificity, and likelihood ratios, is likely to vary greatly in the hands of different clinicians and in varying practice environments. A way to improve the clinical diagnostic process is to cluster OSTs and to use these clusters to either rule in or out different pathologies. The aim of the article is to review the best OST clusters, examine the methodology by which they were derived, and illustrate, with a case study, the use of these OST clusters to arrive at a pathology-based diagnosis.

Positive outcomes with intra-articular glenohumeral injections are independent of accuracy.

BACKGROUND: Shoulder pain is a common, costly, and recalcitrant affliction. One treatment for shoulder pain is intra-articular injection of corticosteroid. Clinical opinion is that injection guided by palpation is accurate and effective, and there is some evidence to support a positive effect of injection on pain. However, great controversy exists as to the accuracy of injection by palpation, whether or not accuracy is important, and what the effect is of accuracy on pain. METHODS: We used a blinded, longitudinal observational design of effectiveness in an effort to determine the accuracy of intra-articular injections and the effect of that accuracy on pain and functional outcomes in patients with various shoulder pathologies. RESULTS: Injection accuracy data were captured on 103 patients. Of the 103 blinded injections, 54 received injections that were identified by fluoroscopy as "in" the capsule, whereas 49 were identified as "outside" the capsule; an accuracy rate of 52.4%. In the 4-week follow up, regardless of group assignment or accuracy of the injection, patients improved significantly (P < .01) from pre- to post-injection. Improvement was typically over by 2.5 points in the Numeric Pain Rating Scale (NPRS) categories, over 8 points on the Short-Form McGill Pain Questionnaire (SFMPQ), and over by 13 points on the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH). DISCUSSION: Our accuracy rate was within the range reported in the literature. Improvements in all subjects with regard to pain and self-reported function occurred even in light of a wide variance in subject duration of symptoms, multiple injectors with varied training, a blinded approach to injection, and multiple injection approaches. CONCLUSIONS: The accuracy of the injection does not appear to depend on the experience of the physician and may be irrelevant in treating shoulder pain of multiple origins.

Postoperative management of pigmented villonodular synovitis in a single subject.

STUDY DESIGN: Case report. BACKGROUND: Pigmented villonodular synovitis (PVNS) is a rare, benign disorder characterized by idiopathic proliferation affecting the synovium of joints, tendon sheaths, and bursae. Diagnosing PVNS in the knee is difficult because the clinical presentation and symptoms mimic those of more common disorders at the joint, such as internal derangements or arthritis. Operative treatment of PVNS typically consists of arthroscopic or open synovectomy, but no reports of postoperative rehabilitation exist. CASE DESCRIPTION: This case describes the postoperative rehabilitation of a 46-year-old female who had left knee surgery secondary to PVNS. Rehabilitation consisted of combined manual therapy, exercise, and gait training to improve function and gait, and cognitive-behavioral techniques to improve self-efficacy. OUTCOMES: All impairments improved in 2.5 months of physical therapy to normal, and the patient estimated 80% to 90% return to function. DISCUSSION: This patient obtained excellent outcomes in 2.5 months of physical therapy following surgery for PVNS. Although no firm conclusions can be drawn from a case report, this patient responded well to a biopsychosocial approach that combined physical therapy with cognitive-behavioral techniques. LEVEL OF EVIDENCE: Therapy, level 4.