Rehabilitation of the painful shoulder.

Managing the painful shoulder in overhead athletes can be difficult because of a lack of time-loss injuries in overhead sports and focusing primarily on either pathoanatomic causes or movement impairments. Although managing the painful shoulder can be challenging, the combination of identifying pathoanatomic causes with movement impairments can provide a more focused rehabilitation approach directed at the causes of shoulder pain. Understanding the potential influence of scapular positioning as well as mobility and/or strength impairments on shoulder pain can help clinicians develop more directed rehabilitation programs. Furthermore, sports-specific methods such as long toss or the use of weighted balls for achieving physiological or performance-based gains have limited empirical evidence regarding their clinical and performance-based benefits, which may impede the rehabilitation process. Applying a comprehensive evaluation approach prior to and throughout the treatment process can assist clinicians with selecting the most appropriate treatment based on patient need. Reconsidering traditional treatments based on existing evidence may help refine the treatment process for overhead athletes with shoulder pain.

Preparing for and Executing the Ideal Posterior Labral Repair.

Posterior labral tears are a source of pain and instability of the shoulder. Despite being relatively uncommon (reported in approximately 10% of instability cases), the incidence of posterior labral tear is increasingly recognized as underestimated in highly active populations. Posterior labral tears can result from a traumatic posterior dislocation or repetitive microtrauma, leading to posterior chondral/labral attrition. Patients often present with vague, deep-seated shoulder discomfort rather than the sensation of instability. Unfavorable results with nonsurgical management will indicate which patients will most benefit from surgery. Arthroscopic stabilization has proven to be an effective and reliable treatment, and many techniques for posterior labral repair have been described. It is important to highlight the evaluation, preparation, and execution of arthroscopic stabilization of an isolated posterior labral repair using high-strength knotless all-suture anchors to allow for a stable, efficient, reproducible, and reliable repair while maintaining a low-profile construct that minimizes damage to the surrounding tissue.

Chronic shoulder injury related to vaccine administration following coronavirus disease 2019 vaccination: a case report.

BACKGROUND: Shoulder injury related to vaccine administration, defined as shoulder pain and limited range of motion occurring after administration in the upper arm, has been previously reported. The symptom resolved completely after treatment with oral nonsteroidal anti-inflammatory drugs or an intraarticular steroid injection, however there have been few reports of long-term symptoms following coronavirus disease 2019 vaccination. This case report describes a healthy, middle-aged, healthcare worker who developed post-vaccination subacromial-subdeltoid bursitis that lasted for more than 6 months after Pfizer-BioNTech coronavirus disease 2019 vaccination. CASE PRESENTATION: A 55-year-old Japanese woman with no significant medical history was vaccinated in the standard site, with the needle direction perpendicular to the skin. Within a few hours after the second vaccination, severe shoulder pain and limited range of motion appeared. Although shoulder range of motion improved, her shoulder pain did not improved for several months, and she consulted an orthopedic doctor 5 months later. Radiographs of her left shoulder did not provide helpful diagnostic information. High intensity in the subacromial-subdeltoid space was seen on short TI inversion recovery of magnetic resonance imaging, showing subacromial-subdeltoid bursitis. She was diagnosed with a shoulder injury related to vaccine administration. The patient was started on an oral anti-inflammatory drug, and the left subacromial space was injected with 2.5 mg of betamethasone with 3 ml of 1% lidocaine without epinephrine every 2 weeks. One month after starting this treatment, since her shoulder pain had not improved, the oral anti-inflammatory drug was switched to tramadol hydrochloride acetaminophen. However, 3 months after switching medication, the shoulder pain continued, and she worked so as to have minimal impact on her shoulder. CONCLUSION: A case of subacromial-subdeltoid bursitis following a second dose of the Pfizer-BioNTech coronavirus disease 2019 vaccine that lasted many months is reported. Injection technique is a modifiable risk factor, the adverse effects of which could potentially be mitigated with appropriate and relevant training of healthcare providers. To prevent this type of case, the appropriate landmark, needle length, and direction should be confirmed.

Functional and Sport-Specific Outcome Following Traumatic First-Time Shoulder Dislocation and Arthroscopic Surgical Repair in Rock Climbers.

INTRODUCTION: Traumatic shoulder dislocations rank among the most common shoulder injuries in climbers, with rising numbers over the last years. The objective of this study was to analyze the outcome following traumatic first-time shoulder dislocation and subsequent surgical treatment in this population. METHODS: In a retrospective study, climbers who experienced a traumatic shoulder dislocation were treated with an arthroscopic repair of the labrum-ligament complex (LLC). The functional outcome was assessed with a standardized questionnaire and clinical examination, including the Constant Murley and Single Assessment Numeric Evaluation scores. The sport-specific outcome was analyzed using the Union Internationale des Associations d'Alpinisme (UIAA) scale of difficulty and a sport-specific outcome score. RESULTS: The functional and sport-specific outcome for 27 climbers (20 men; 7 women; 3 with bilateral injuries; age, 34±11 [17-61] y; data presented as mean±SD [range]) was assessed 53±29 (12-103) mo after surgery. The postoperative Constant Murley score was 95±8 (67-100) points. At follow-up, 93% (n=25) of patients had started climbing again. Twenty-one climbers (78%) reached a climbing level within the range of ±0.33 UIAA grades of their initial capability or even exceeded their preinjury grade. Only 7% (n=2) of the patients had a recurrent shoulder dislocation, leading to a secondary surgery, and, therefore, required ongoing postoperative treatment at the time of follow-up. CONCLUSIONS: Arthroscopic repair of the LLC following first-time traumatic shoulder dislocation in climbers shows a good outcome and a low recurrence rate. After surgery, most patients are able to regain a high level of rock-climbing ability.

Magnetic resonance arthrographic demonstration of extension of labral defects in paraglenoid labral cysts.

OBJECTIVE: This study aimed to investigate the extension of labral tears associated with paraglenoid labral cysts by magnetic resonance arthrography. METHODS: The magnetic resonance and magnetic resonance arthrography images of patients with paraglenoid labral cysts who presented to our clinic between 2016 and 2018 were examined. In patients with paraglenoid labral cysts, the location of the cysts, the relation between the cyst and the labrum, the location and extent of glenoid labrum damage, and whether there was contrast medium passage into the cysts were investigated. The accuracy of magnetic resonance arthrographic information was evaluated in patients undergoing arthroscopy. RESULTS: In this prospective study, a paraglenoid labral cyst was detected in 20 patients. In 16 patients, there was a defect in the labrum adjacent to the cyst. Seven of these cysts were adjacent to the posterior superior labrum. In 13 patients, there were contrast solution leak into the cyst. For the remaining seven patients, no contrast-medium passage was observed in the cyst. Three patients had sublabral recess anomalies. Two patients had rotator cuff muscle denervation atrophy accompanying the cysts. The cysts of these patients were larger compared to those of the other patients. CONCLUSION: Paraglenoid labral cysts are frequently associated with the rupture of the adjacent labrum. In these patients, symptoms are generally accompanied by secondary labral pathologies. Magnetic resonance arthrography can be successfully used not only to demonstrate the association of the cyst with the joint capsule and labrum, but also to reliably demonstrate the presence and extension of labral defects.

High Incidence of Combined and Posterior Labral Tears in Military Patients With Operative Shoulder Instability.

BACKGROUND: Anterior shoulder instability is the pattern most commonly reported in the civilian population, but military servicemembers may represent a unique population. At 1.7 per 1000 person-years, servicemembers not only have a higher incidence of instability events compared with civilians (reported rate of 0.2-0.8), but the distribution of labral tears in the military may differ significantly as well. HYPOTHESIS: The incidence of combined and posterior labral tears in the military population will be greater than numbers previously reported. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The Wounded, Ill, and Injured Registry, a Department of Defense patient reported outcomes data collection platform that includes all military branches, was queried retrospectively for all patients who had undergone a primary arthroscopic or open shoulder stabilization procedure (Current Procedural Terminology codes 29806, 23455, 23462) between October 2016 and January 2019. Demographic information was obtained through intake forms completed by patients at the time of enrollment into the Military Orthopaedics Tracking Injuries and Outcomes Network. Tear location was determined arthroscopically and labeled as anterior, inferior, posterior, superior, or any combination thereof. Chi-square analysis was used to compare the percentage of patients with isolated anterior, isolated posterior, isolated inferior, or combined labral tears in the current study cohort with those in a previously reported cohort of patients with operative shoulder instability at a single military treatment facility. RESULTS: A total of 311 patients were included who had undergone primary shoulder stabilization during the study period. Of these patients, 94 (30.2%) had isolated anterior tears, 76 (24.4%) had isolated posterior tears, and 136 (43.7%) had combined tears. We observed a higher percentage of combined tears in our data set than in a data set from a single military treatment facility (χ2(2) = 48.2; P < .00001). Chi-square analysis demonstrated that significantly more female patients had an isolated anterior labral tear (51.2%) compared with male patients (27.1%; χ2(2) = 9.4; P = .009). CONCLUSION: The incidence of combined and posterior labral tears in the military population is greater than numbers previously reported in both military and civilian populations.

Concomitant glenohumeral injuries in patients with distal clavicle fractures undergoing arthroscopic-assisted surgery: a systematic review.

BACKGROUND: To determine the incidence of concomitant intra-articular glenohumeral injuries in patients undergoing surgical management from distal clavicle fractures (DCF) with shoulder arthroscopy and their impact on outcome. METHODS: This systematic review was conducted following the PRISMA guidelines. PubMed, EMBASE, and Virtual Health Library databases were accessed in October 2021. All the clinical studies evaluating the surgical management of DCF and using concomitant intra-operatory shoulder arthroscopy were included. Studies that did not specify the concomitant injury type were not eligible. Data from the incidence of intra-articular glenohumeral injuries, injury type, length of the follow-up, and clinical outcomes were retrieved. The quantitative content assessment was performed using the STROBE statement checklist. Evaluation of the publication bias of the included studies was performed using the risk of bias assessment tool for systematic reviews. RESULTS: Data from five retrospective and five prospective cohort studies were analyzed. Eight of the included studies were conducted on patient cohorts with Neer type II injuries. Data pooling revealed a mean of 17.70% of concomitant glenohumeral injuries, whereas 84.21% of them required additional surgical management (Table 1). Rotator cuff injuries, labral tears, and biceps pulley lesions were the most common concomitant injuries. CONCLUSION: Preoperative MRI or diagnostic arthroscopy to evaluate glenohumeral associated injuries to DCF should be recommended.

Patterns of Nerve Injury and Recovery Rates of Infraclavicular Brachial Plexus Lesions Following Anterior Shoulder Dislocation.

PURPOSE: We reviewed our cases of infraclavicular brachial plexus injuries associated with anterior shoulder dislocation to determine patterns of injury, recovery rates, and factors associated with a poor motor outcome. METHODS: This was a retrospective review of patients who had sustained a concomitant nerve injury following dislocation of the glenohumeral joint treated with closed manipulation. The data collected included patient demographics, injury factors, and patterns of neurological deficits. The Medical Research Council (MRC) grade for motor power was the primary outcome measure, where a grade of 4 or 5 was regarded as achieving good motor recovery. Univariate and multivariable analyses were used to identify factors associated with persistent motor weakness (MRC grades 0-3) at the final follow-up. RESULTS: Between 2015 and 2019, 61 patients were assessed. There were 36 males and 25 females, with a median age of 64 years (interquartile range [IQR], 53-73 years). Four patterns of injury were identified: (1) isolated axillary nerve lesions; (2) single cord lesions; (3) combined lesions involving the medial and posterior cords; and (4) diffuse lesions affecting all 3 cords. Of 28 patients with isolated axillary nerve injuries, 22 recovered. All lateral cord injuries (11/11) and 20 of 24 posterior cord injuries recovered spontaneously. Recovery of hand intrinsic function from medial cord injuries had the worst outcome, with 14 of 27 patients not recovering beyond MRC grades 0 to 3. The median duration of dislocation before reduction was 6 hours (IQR, 3-12 hours). A multivariate analysis showed an association between the duration of shoulder dislocation and the likelihood of persistent motor weakness. CONCLUSIONS: Shoulder dislocations with motor deficits should be regarded as orthopedic emergencies and reduced expediently. Persistent motor weakness may be associated with a prolonged duration of dislocation prior to glenohumeral relocation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Career Longevity and Performance After Shoulder Instability in National Football League Athletes.

PURPOSE: To investigate the career longevity, game utilization, and performance of National Football League (NFL) athletes after glenohumeral instability events treated operatively versus nonoperatively. METHODS: Using public resources, we identified NFL players who sustained a shoulder instability event from September 2000 to February 2019. Players with prior shoulder instability, without NFL experience before injury, or who did not return to play (RTP) after injury were excluded. Demographic information, utilization (games and seasons), and season approximate value (SAV) statistics were recorded 1 year prior to injury and 3 years after RTP. Statistical analysis compared utilization and the SAV after RTP for athletes managed operatively versus nonoperatively. RESULTS: We identified 97 NFL players who sustained their first instability event while playing in the NFL, 91 of whom returned to play (93.8%). Quarterbacks were significantly more likely to undergo immediate surgical management compared with players in other positions (P = .023). The final analysis included 58 players managed operatively and 33 managed nonoperatively by the end of the index season. Players treated operatively played in significantly more seasons after RTP during their remaining careers (4.1 ± 2.7 seasons vs 2.8 ± 2.5 seasons, P = .015). There were no differences in games played or started, offensive or defensive snap count percentage, or performance (SAV) before and after injury when compared between cohorts (P > .05). After surgical stabilization, time to RTP (36.62 ± 10.32 weeks vs 5.43 ± 12.33 weeks, P < .05) and time interval before recurrent instability (105.7 ± 100.1 weeks vs 24.7 ± 40.6 weeks, P < .001) were significantly longer than with nonoperative treatment. Additionally, the operative cohort experienced less recurrent instability (27% vs 50%, P = .035). CONCLUSIONS: Athletes who RTP in the NFL after a shoulder instability injury do so with a similar workload and performance irrespective of surgical or nonsurgical management. Whereas nonoperative treatment is associated with faster RTP, operative management is associated with fewer recurrent instability events, greater time between recurrent instability events, and greater career longevity. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

No differences between conservative and surgical management of acromioclavicular joint osteoarthritis: a scoping review.

PURPOSE: To conduct a scoping review to clarify the management of acromioclavicular joint osteoarthritis, as well as to identify any existing gaps in the current knowledge. METHODS: Studies were identified by electronic databases (Ovid, Pubmed) from their inception up to April 2nd, 2020. All studies reporting functional outcomes after conservative or surgical treatment of acromioclavicular joint osteoarthritis, either primary or secondary to trauma or distal clavicle osteolysis, were included. Following data were extracted: authors, year of publication, study design (prospective or retrospective), LOE, number of shoulders treated conservatively or surgically, patients' age, OA classification, type of conservative treatment, surgical approach, surgical technique, functional outcomes, complications, revisions, and length of follow-up. Descriptive statistics was used. Quality appraisal was assessed through the Cochrane risk of bias tool for LOE I/II studies, while the MINORS checklist was used for LOE III/IV studies. RESULTS: Nineteen studies were included for a total of 861 shoulders. Mean age of participants was 48.5 ± 7.4 years. Mean follow-up was 43.8 ± 29.9 months. Four studies reported functional results after conservative treatment, whereas 15 studies were focused on surgical management. No studies directly compared conservative and surgical treatment. Seven studies reported a surgical approach after failure of previous conservative treatment. All studies reported functional improvement and pain relief. Complication rate was low. Overall methodological quality of included studies was very low. CONCLUSION: Conservative and surgical treatments are both effective in acromioclavicular joint osteoarthritis management. However, available data did not allow to establish the superiority of one technique over another. LEVEL OF EVIDENCE: Level IV.

Arthroscopic Bankart repair with remplissage versus Latarjet procedure for management of engaging Hill-Sachs lesions with subcritical glenoid bone loss in traumatic anterior shoulder instability: a systematic review and meta-analysis.

BACKGROUND: A large engaging Hill-Sachs lesion (HSL) with subcritical glenoid bone loss (GBL) is approached through either increasing the glenoid arc by the Latarjet procedure or converting the HSL to an extra-articular defect by arthroscopic Bankart repair with remplissage (BRR). Until now, there has been no evidence-based consensus about which of these 2 most appropriate procedures is the better surgical choice. The purpose of this study was to analyze the current literature comparing results of BRR vs. the Latarjet procedure in the treatment of engaging HSLs with subcritical GBL. METHODS: A comprehensive review of the PubMed and Cochrane databases was completed for studies that compared the clinical outcomes and complications of BRR vs. the Latarjet procedure with minimum follow-up of 2 years. The outcome measures analyzed included postoperative Rowe score, visual analog scale pain score, postoperative range of motion (ROM), and rates of recurrent instability and other complications. RESULTS: Overall, 4 articles (level III evidence in 3 and level II in 1) were included from an initial 804 abstracts. The study population consisted of a total of 379 patients, of whom 194 underwent BRR and 185 underwent the Latarjet procedure. There were no unacceptable differences in baseline characteristics between the 2 groups. For the rate of recurrent instability, both groups had comparable risk ratios (RRs) (N = 379; RR, 0.72; 95% confidence interval [CI], 0.37-1.41). The risk of other complications was significantly increased with the Latarjet procedure (by about 7 times) relative to the the BRR procedure (N = 379; RR, 7.37; 95% CI, 2-27). Both groups had comparable postoperative Rowe scores (n = 190; mean difference [MD], -0.9; 95% CI, -3.45 to 1.7) and visual analog scale pain scores (n = 347; MD, -0.2; 95% CI, -0.6 to 0.2). Moreover, both groups had comparable postoperative external rotation ROM (MD, -1.7°; 95% CI, -9.4° to 6°) and internal rotation ROM (MD, 1.95°; 95% CI, -5.35° to 9.25°). There was substantial heterogeneity in the effect of both procedures on postoperative pain and ROM (external rotation and internal rotation). CONCLUSION: Both the BRR and Latarjet procedures are effective for the management of engaging HSLs with subcritical GBL and give comparable clinical outcomes. However, given the fewer overall postoperative complications, remplissage may be safer. The results of the included studies were adequately consistent for most analyzed outcomes. However, for the intervention effect on postoperative pain and ROM, there was a small body of evidence, limiting the strength of the reported conclusions.

Operative Treatment of Anterior Shoulder Instability A Network Meta-Analysis.

BACKGROUND: Traumatic anterior shoulder instability is a common clinical problem among athletic populations, with several surgical treatment options available. The optimal treatment remains undetermined. Currently the main current treatment options are the Latarjet procedure or open or arthroscopic Bankart repair. The purpose of this study was to network meta-analyze the recent evidence to ascertain if the open Latarjet procedure and open or arthroscopic Bankart repair result in lower recurrence rates and subsequent revision procedures. The results were ranked with the P-score. METHODS: A literature search was performed based on the PRISMA guidelines. Cohort studies comparing any of the open Latarjet procedure and open or arthrosopic Bankart repair for anterior shoulder instability were included. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using R. RESULTS: Twenty-nine studies with 2,474 patients were included. The open Latarjet procedure resulted in lower rates of recurrent instability and revisions due to recurrence compared to both open and arthroscopic Bankart repairs. The open Latarjet procedure resulted in the highest rate of return to play. However, the open Latarjet procedure also resulted in the highest complication rate. CONCLUSION: Our network meta-analysis found the open Latarjet procedure had the lowest recurrence rates, lowest revisions rates, and highest rates of return to play in the surgical treatment of anterior shoulder instability. However, the Latarjet procedure has been shown to result in a higher complication rate, which needs to be considered when deciding which stabilization procedure to perform.

Outcomes of Revision Surgery for a Failed Prior Latarjet Procedure A Systematic Review.

PURPOSE: This study systematically reviewed the literature for outcomes following revision surgery for a failed prior Latarjet procedure. METHODS: Two independent reviewers performed the literature search based on PRISMA guidelines using the EMBASE, MEDLINE, and The Cochrane Library databases. Studies in which the Latarjet procedure was performed as a revision procedure following failed prior shoulder instability surgery were included. Clinical outcomes analyzed were: 1. functional outcomes, 2. recurrent instability, 3. range of motion, and 4. COMPLICATIONS: Statistical analysis was performed using IBM SPSS. RESULTS: There were seven studies with 161 patients (162 shoulders) included. Four studies used a bone-block procedure, three used arthroscopic soft-tissue stabilization, and the mean follow-up was 49.8 months. The most commonly reported functional outcome measure was the Rowe score, with a weighted mean average of 79.7, with 82.9% of patients having good to excellent outcomes. Return to play was possible for 73.8% of patients, with 64.2% of those returning to at least the same level of competition. The overall recurrence rate was 9.5%, with 3.6% and 5.9% experiencing recurrent dislocations and subluxations, respectively. The overall revision rate was 4.2%, with all patients undergoing revisions due to recurrence. There were no reported neurovascular complications. Instability arthropathy was reported in 43.3% of patients. CONCLUSION: Surgical management following a failed Latarjet procedure results in moderate rates of recurrent instability and has a low intraoperative and postoperative complication rate. Additionally, the results across all techniques appear similar, with no procedure being identified as the gold-standard in the literature. However, there was a concerning rate of instability arthropathy, which may be related to the failure of a bony procedure.

MR arthrographic evaluation of posterior paraglenoid labral cysts: a retrospective study.

BACKGROUND: Paraglenoid labral cysts (PLCs) around the shoulder are uncommon. Magnetic resonance imaging (MRI) is the primary imaging modality for the description of PLCs. PURPOSE: The purpose of this study was to evaluate PLCs in the posterior part of the glenoid bone via MR arthrography as well as to describe associated labral abnormalities. MATERIAL AND METHODS: This retrospective study included 14 patients, diagnosed with 15 posterior PLCs at MR arthrography between 2007 and 2012. Conventional MRI and MR arthrography were used for all patients. RESULTS: A total of 15 PLCs were detected in 14 patients with eight located on the right shoulder and six on the left shoulder. One case had two PLCs. While two cysts were multiloculated, the remaining 13 were seen as unilocated simple cysts. Moreover, 14 of 15 posterior PLCs (60%) were associated with labral tears at MR arthrography. The cysts in proximity to the glenoid labrum were posterosuperior in 33.3% (n = 5), mid-posterior in 36.7% (n = 7), and postero-inferior in 20% (n = 3). The majority of patients with posterosuperior and mid-posterior cysts had an associated superior labral tear from anterior to posterior (SLAP) lesions. Four of six patients with mid-posterior cysts had minimal denervation atrophy in the infraspinatus muscle. CONCLUSION: Posterior PLCs are mostly associated with posterior labral defects. The majority of cysts localized in the posterosuperior and mid-posterior were also associated with SLAP lesions. Denervation atrophy in the infraspinatus muscle may frequently accompany mid-posterior PLCs.

Epidemiology of Shoulder Instability Injuries in Collision Collegiate Sports From 2009 to 2014.

PURPOSE: To describe the types, mechanisms, and severity of shoulder instability injuries in collegiate collision athletes during the 2009-2010 through 2013-2014 academic years using the National Collegiate Athletic Association Injury Surveillance Program; to compare the injury incidence between men's collision sports and their women's non-collision counterparts, when possible; and to compare injury outcomes between Divisions I, II, and III. METHODS: Data regarding men's football, wrestling, ice hockey, and lacrosse, as well as women's ice hockey and lacrosse, were obtained. Injuries requiring attention from a health care provider were reported. Incidence rates per 100,000 athlete-exposures (AEs) were calculated with 95% confidence intervals (CIs). Analysis of variance was used to compare time loss (TL), and χ2 analysis was used to compare surgery rates between divisions. RESULTS: A total of 445 shoulder instability injuries occurred in 1,421,561 AEs from 2009-2010 to 2013-2014 (incidence rate, 31.30 injuries/100,000 AEs; 95% CI, 28.4-34.21 injuries/100,000 AEs). Subluxation accounted for 59.1% of injuries, with anterior subluxation (35.3%) being the most common injury. Dislocation resulted in the most TL per injury (17.58 days). Mean TL for all injuries was 8.17 days (standard deviation, 7.21 days). When non-time-loss injuries were excluded from analysis, players experienced a mean TL of 18.34 days (standard deviation, 8.44 days). Divisions I (4.77 days), II (20.52 days), and III (11.23 days) differed significantly in mean TL (P = .01). Of the injuries, 29.3% required surgery. The surgery rates for Divisions I (32.9%), II (38.1%), and III (19.4%) also differed significantly (P = .04). Men's ice hockey and lacrosse players sustained a 2.17-fold (95% CI, 1.04-4.50) higher incidence of shoulder instability than their female counterparts. CONCLUSIONS: Anterior subluxation and dislocation accounted for 52.1% of all shoulder instability injuries. Injured athletes missed 8 days on average, and nearly 30% of injuries required surgery. Surgery rates and TL were significantly different between Divisions I, II, and III. Female athletes playing non-collision ice hockey and lacrosse experienced significantly lower shoulder instability rates than their male counterparts. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

[Posttraumatic and postoperative shoulder stiffness : Trauma, rotator cuff reconstruction, instability operations and shoulder arthroplasty]. / Posttraumatische und postoperative Schultersteife : Trauma, Rotatorenmanschettenrekonstruktion, Instabilitätsoperationen und Arthroplastik.

Apart from primary or idiopathic frozen shoulder, the secondary form of glenohumeral stiffness can also develop after trauma or surgery. The cause for these secondary forms of restricted range of motion can be distinguished into intra-articular and extra-articular factors. Posttraumatic stiffness can develop after minor or major trauma to the bony or soft tissues of the shoulder girdle. After minor trauma the course and clinical presentation is similar to the primary form as pathomorphological correlates are often not detectable; therefore, treatment protocols are adapted according to those for primary shoulder stiffness. Shoulder stiffness after major trauma is mainly caused by scarring and adhesions of gliding structures and often necessitates surgical release if resolution under conservative treatment fails. Postoperative shoulder stiffness is a common problem after rotator cuff surgery or fracture fixation, even though incidences vary widely between different surgical procedures. Apart from the abovementioned scarring, overstuffing implants or tightening of soft tissue structures can lead to restricted range of motion. Stiffness after shoulder arthroplasty is rare and should prompt further diagnostic work-up to differentiate implant, surgery or patient-specific causes. Furthermore, an inflammatory shoulder stiffness similar to the primary or minor trauma form can develop after surgery. Reviewing the literature, shoulder stiffness has been reported most often after rotator cuff reconstruction surgery, followed by fracture fixation surgery, instability operations and lastly shoulder arthroplasty.

Do patients with minor shoulder instability have a different outcome from those with recurrent anteroinferior instability?

PURPOSE: Minor or anterosuperior shoulder instability (MSI) is a relatively new concept with other characteristics than recurrent anteroinferior instability (TUBS). MSI includes patients without history of dislocation, with non-specific clinical symptoms and signs but with indications of laxity of (SGHL)/MGHL with isolated injury of (SGHL)/MGHL seen during arthroscopy. TUBS patients typically present with recurrent anteroinferior instability with at least labral injury of the anterior band of the IGHL. In this study, we focus on the postoperative (rehabilitation) course. Our hypothesis is that its duration is prolonged in patients with MSI when compared to those with TUBS. METHODS: Thirty-five patients with isolated anterosuperior capsuloligamentous lesions identified during arthroscopic surgery (group I-MSI) and 65 with at least an anteroinferior capsuloligamentous lesion (group II-TUBS) completed a survey that included a questionnaire enquiring into relief of pain and return to activity, the Oxford Shoulder Instability Score (OSIS) and the Western Ontario Shoulder Instability index (WOSI). Final follow-up occurred at a mean of 76 months postoperatively. RESULTS: Pain at night, at rest and during overhead activities disappeared later in group I than in group II (respectively, p = 0.03; 0.01; 0.01). Patients with MSI returned later to professional activities (p = 0.02) and to the same sport (p = 0.01). In addition, they had worse outcome as measured by OSIS (p = 0.01) and WOSI (p = 0.07). CONCLUSION: Patients with MSI have poorer prospects regarding time to relief of pain, return to work and sports and outcome scores compared to patients with TUBS.

Arthroscopic Bankart repair following traumatic recurrent shoulder dislocation: A prospective review of 30 cases.

BACKGROUND: Literature on outcomes of arthroscopic Bankart repair at the intervening time intervals in traumatic recurrent dislocation of shoulder joint is limited. STUDY DESIGN: Case series. SUBJECTS AND METHODS: A prospective review of 30 shoulders, aged 20-40 years with clinically and magnetic resonance imaging established findings that were treated with primary arthroscopic Bankart repair and followed up for a minimum of 2 years. Outcomes were evaluated using Rowe score and University of California at Los Angeles (UCLA) scoring system. RESULTS: The mean age was 26.40 years. All patients had definite trauma history. Average number of dislocation was 13.77 + 18.435 (range: 3-100). Time duration from first dislocation to surgery was an average of 4.80 + 3.576 years. The average size of the lesion was approximately 31% of the glenoid circumference. The number of suture anchors used for fixation did not correlate significantly with any of the scores. The mean Rowe and UCLA scores were 94.16 ± 9.7 and 33.83 ± 3.32, respectively, at final follow-up. The average duration of hospital stay was 7 days. Of the 30 patients, 2 (6.66%) had dislocation events post-operatively. Returns to pre-injury level were available for 27 (90%) of 30 patients. Multivariate analysis of independent Variables: age; side and number of dislocations, time to surgery, duration of surgery, size of lesion, number of anchors, and concurrent Hill-Sachs lesion, shown to have no significant relationship to outcomes. CONCLUSION: Arthroscopic Bankart repair is an effective and safe technique for treating anterior glenohumeral instability in patients with recurrent traumatic shoulder dislocation.

Do intra-articular pathologies accompanying symptomatic acromioclavicular joint degeneration vary across age groups?

OBJECTIVES: This study aims to evaluate the accompanying intra-articular pathologies in patients who underwent arthroscopic distal clavicle resection (DCR) for symptomatic acromioclavicular (AC) joint degeneration based on age groups and to reveal which additional pathologies should be considered across different age groups during physical examination of patients suspected of AC joint degeneration. PATIENTS AND METHODS: The study included 156 patients (55 males, 101 females; mean age 57.2±10.0 years; range, 35 to 80 years) who underwent arthroscopic DCR between January 2006 and December 2017 and had at least one clinical positive test for AC joint degeneration during the preoperative physical examination. The patients were divided into three groups as those aged <50 years (group 1), between 50-65 years (group 2), and >65 years (group 3). The concomitant intra-articular pathologies were evaluated across different age groups and compared between the groups. RESULTS: Concomitant intra-articular pathologies were detected in 117 (75%) of a total of 156 patients. Additional pathology rate increased with increasing age (p=0.002). More than one concomitant intra-articular pathologies were detected in 37 patients (23.7%). This rate increased with increasing age (p=0.002). The number of patients with superior labrum anterior posterior (SLAP) lesion as the only additional pathology was 33 (21.2%). This rate decreased with increasing age (p=0.015). In group 1, the rate of concomitant SLAP lesion was 44.1%. CONCLUSION: The high incidence of intra-articular pathologies accompanying symptomatic AC joint degeneration raises the importance of careful physical examination, detailed imaging, and arthroscopic surgery to obtain good results in patients scheduled for DCR. The frequency of AC joint degeneration and concomitant SLAP lesions, particularly in younger patients, should be considered during clinical examinations.

Bilateral shoulder proprioception deficit in unilateral anterior shoulder instability.

HYPOTHESIS AND BACKGROUND: Proprioception is an important element of shoulder dynamic stability. It has been shown to be affected in cases of capsular or labral injuries of the glenohumeral joint. Therefore, this study was conducted to investigate bilateral shoulder proprioception by active reproduction of joint position both in patients with post-traumatic recurrent unilateral shoulder instability and in normal healthy volunteers. METHODS: We compared 41 patients, comprising 11 female and 30 male patients with an average age of 25.6 years (range, 18-39 years), with post-traumatic unilateral anterior shoulder instability with a control group of 27 healthy volunteers with no history of shoulder problems and with normal shoulder function during examination. All patients were examined using a high-accuracy computer-controlled electronic goniometer (Propriometer). The error of active reproduction of joint position (EARJP) was measured in abduction, flexion, external rotation, and internal rotation in both shoulders. RESULTS: We observed a significant deficit in the EARJP in the unstable shoulders within the instability group. Surprisingly, similar results were recorded for the contralateral, unaffected shoulders within this group of patients compared with the control group. Joint acuity increased with higher elevation of the arm position. CONCLUSION: Unilateral shoulder injuries, resulting in instability, affect proprioception in both shoulders, as demonstrated by an increased EARJP. This is the first report of unilateral shoulder instability coexisting with inferior proprioception in both shoulders.