The Posterior Shoulder Instability Questionnaire (PSI-Q): Internal consistency, content and criterion validity, responsiveness, and reliability of a new tool for the assessment of posterior shoulder instability.

INTRODUCTION: Posterior shoulder instability (PSI) is an increasingly recognized cause of shoulder dysfunction particularly in young active patients and certain athlete populations. When evaluating the efficacy of treatment for PSI, specific outcome measures for this population are essential. The aim of the current research was to describe the development and evaluation of a patient reported outcome measure (PROM) specific for PSI. METHODS: A retrospective cohort study design of patients with PSI was used to develop and evaluate the "Posterior Shoulder Instability Questionnaire (PSI-Q)". Items for PSI-Q were generated through an expert focus group and existing questionnaires. Preliminary data analysis identified redundancy of items and resulted in the PSI-Q being refined. The final PSI-Q was evaluated on 128 patients with PSI with a structural lesion requiring surgical intervention. Participants were excluded in the absence of a posterior glenohumeral joint lesion. Internal consistency (Cronbach α and corrected item-total correlation), content validity, criterion validity, responsiveness, and test-retest reliability (intraclass correlation coefficient; ICC) were examined. Content validity, criterion validity and responsiveness were compared with the Melbourne Instability Shoulder Score (MISS) and the Western Ontario Shoulder Index (WOSI). The minimum detectable change score (MDC) was calculated. RESULTS: The Cronbach α for the total scale pre and post-intervention was high (α = 0.97). All five domains (Pain, Instability/Weakness/Stiffness, Function, Occupation and Sport, and Quality of Life and Satisfaction) demonstrated acceptable internal consistency for each subsection and the overall score of the scale (α > 0.70). The corrected-item total correlation for each domain were within an acceptable range. The responsiveness of the PSI-Q questionnaire was excellent (effect size, 2.06; standard response mean, 1.34) and was higher than the MISS and WOSI. There were no relevant floor effects and one ceiling effect. Reliability was excellent (ICC (1,1) = 0.93) and the calculated MDC was 10.9 points. DISCUSSION: This study designed and validated a questionnaire specific for measuring symptoms and function in people with structural PSI requiring surgery. The PSI-Q demonstrates good measurement properties and provides an MDC that is useful for researchers and clinicians. In structural PSI, the PSI-Q has a higher responsiveness and more accurately reflects a patient's overall perceived shoulder status compared to current patient reported outcomes for shoulder instability. The psychometric properties of the PSI-Q are still to be determined in a non-surgical population.

Effect of a physiotherapy-directed rehabilitation programme on patients with multidirectional instability of the glenohumeral joint: a multimodal interventional MRI study protocol.

INTRODUCTION: Altered neuromuscular control of the scapula and humeral head is a typical feature of multidirectional instability (MDI) of the glenohumeral joint, suggesting a central component to this condition. A previous randomised controlled trial showed MDI patients participating in the Watson Instability Program 1 (WIP1) had significantly improved clinical outcomes compared with a general shoulder strength programme. The aim of this paper is to outline a multimodal MRI protocol to identify potential ameliorative effects of the WIP1 on the brain. METHODS AND ANALYSIS: Thirty female participants aged 18-35 years with right-sided atraumatic MDI and 30 matched controls will be recruited. MDI patients will participate in 24 weeks of the WIP1, involving prescription and progression of a home exercise programme. Multimodal MRI scans will be collected from both groups at baseline and in MDI patients at follow-up. Potential brain changes (primary outcome 1) in MDI patients will be probed using region-of-interest (ROI) and whole-brain approaches. ROIs will depict areas of functional alteration in MDI patients during executed and imagined shoulder movements (MDI vs controls at baseline), then examining the effects of the 24-week WIP1 intervention (baseline vs follow-up in MDI patients only). Whole-brain analyses will examine baseline versus follow-up voxel-wise measures in MDI patients only. Outcome measures used to assess WIP1 efficacy will include the Western Ontario Shoulder Index and the Melbourne Instability Shoulder Score (primary outcomes 2 and 3). Secondary outcomes will include the Tampa Scale for Kinesiophobia, Short Form Orebro, Global Rating of Change Score, muscle strength, scapular upward rotation, programme compliance and adverse events. DISCUSSION: This trial will establish if the WIP1 is associated with brain changes in MDI. ETHICS AND DISSEMINATION: Participant confidentiality will be maintained with publication of results. Swinburne Human Research Ethics Committee (Ref: 20202806-5692). TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trial Registry (ACTRN12621001207808).

Posterior Shoulder Instability in Tennis Players: Aetiology, Classification, Assessment and Management.

Background: Micro-traumatic posterior shoulder instability (PSI) is an often missed and misdiagnosed pathology presenting in tennis players. The aetiology of micro-traumatic PSI in tennis players is multifactorial, including congenital factors, loss of strength and motor control, and sport-specific repetitive microtrauma. Repetitive forces placed on the dominant shoulder, particularly combinations of flexion, horizontal adduction, and internal rotation contribute to the microtrauma. These positions are characteristic for kick serves, backhand volleys, and the follow-through phase of forehands and serves. The aim of this clinical commentary is to present an overview of the aetiology, classification, clinical presentation, and treatment of micro-traumatic PSI, with a particular focus on tennis players. Level of Evidence: 5.

Advances in the Non-Operative Management of Multidirectional Instability of the Glenohumeral Joint.

Multidirectional instability (MDI) of the glenohumeral joint refers to symptomatic subluxations or dislocations in more than one direction. The aetiology of MDI is multifactorial, which makes the classification of this condition challenging. A shoulder rehabilitation program is the initial recommended treatment for MDI, however available rehabilitation programs have varying levels of evidence to support their effectiveness. In 2016, we published the details of an evidence-based program for MDI that has been evaluated for efficacy in two single-group studies and a randomised controlled trial. In 2017, we published a clinical commentary on the aetiology, classification, and treatment of this condition. The aim of this paper is to provide an update on the components of these publications with a particular focus on new advances in the non-operative management of this condition.

Rehabilitation for atraumatic shoulder instability in circus arts performers: delivery via telehealth.

BACKGROUND: The Watson Instability Program (WIP1) is current best evidence for conservative management of atraumatic shoulder instability, but it is unknown if this program can be effectively delivered via tele-consultation. The purpose of this longitudinal pre-post intervention study was to determine the effects of the WIP1 on patient-reported outcome measures, scapular position, shoulder strength, and handstand stability in student circus performers with atraumatic shoulder instability when delivered via tele-consultation. METHODS: Student circus performers aged between 15 and 35 years from the National Institute of Circus Arts were recruited. A 12-week shoulder exercise program was delivered via tele-consultation during the Melbourne, Australia COVID-19 (coronavirus disease 2019) lockdown. The primary outcome measures were the Western Ontario Shoulder Instability Index score and the Melbourne Instability Shoulder Scale score. Secondary outcomes measures included the Orebro Musculoskeletal Pain Questionnaire, the Tampa Scale for Kinesiophobia, and physical assessment measures including strength via handheld dynamometry, scapular position using an inclinometer, and handstand stability via center-of-pressure fluctuation. Patient-reported outcomes were collected at baseline and 6-week, 12-week, 6-month, and 9-month time points, and physical outcomes were measured at baseline and 9-month time points. A repeated-measures mixed model (with effect sizes [ESs] and 95% confidence intervals [CIs]) was used to analyze patient-reported outcomes, handstand data, strength, and scapular measures. Significance was set at P < .05. RESULTS: Twenty-three student circus arts performers completed the study. Significant improvements were found in both Western Ontario Shoulder Instability Index scores (effect size [ES], 0.79 [95% CI, 0.31-1.33] at 6 weeks; ES, 1.08 [95% CI, 0.55-1.6] at 12 weeks; ES, 1.17 [95% CI, 0.62-1.78] at 6 months; and ES, 1.31 [95% CI, 0.74-1.95] at 9 months; P < .001) and Melbourne Instability Shoulder Scale scores (ES, 0.70 [95% CI, 0.22-1.22] at 6 weeks; ES, 0.83 [95% CI, 0.34-1.37] at 3 months; ES, 0.98 [95% CI, 0.46-1.54] at 6 months; and ES, 0.98 [95% CI, 0.43-1.50] at 9 months; P < .001), as well as Orebro Musculoskeletal Pain Questionnaire scores at all follow-up time points. The Tampa Scale for Kinesiophobia scores reached significance at 6 weeks and 12 weeks. Following rehabilitation, we found statistically significant increases in shoulder strength in all positions tested and increased scapular upward rotation measured at end-of-range abduction, as well as during loaded external rotation. The affected arm showed greater instability than the unaffected arm with a significant intervention effect on the affected arm showing a greater consistent anterior-posterior movement pattern. CONCLUSION: In a group of circus performers with atraumatic shoulder instability, treatment with the WIP1 via telehealth resulted in clinically and statistically significant improvements in shoulder symptoms and function.

Intra-Rater and Inter-Rater Reliability of Hand-Held Dynamometry for Shoulder Strength Assessment in Circus Arts Students.

The purpose of this study was to establish the intra-rater and inter-rater reliability of isometric shoulder strength assessment using a hand-held dynamometer (HHD) in functional joint positions in student circus artists with symptomatic atraumatic shoulder instability. METHODS: Over two testing sessions, two experienced physiotherapists assessed the shoulder strength of 24 student circus artists with clinically diagnosed atraumatic shoulder instability. Both the symptomatic and asymptomatic shoulder was assessed using a HHD in 10 functional positions. Intra-class correlation coefficients (ICCs) were calculated to determine the reliability of strength measurements. RESULTS: All examined positions showed moderate-high intra-rater and inter-rater reliability. External rotation at 0° and internal rotation in horizontal flexion at 45° revealed the most reliable results, and the shrug position the least reliable. Inter-rater and intra-rater reliability was high and demonstrated similar results in symptomatic and asymptomatic shoulders by both raters. DISCUSSION: This study demonstrated clinical applicability in reliably measuring functional strength in symptomatic atraumatic instability or asymptomatic shoulders when assessed by experienced therapists using an HHD.

The Specific AC Score (SACS): a new and validated method of assessment of isolated acromioclavicular joint pathology.

BACKGROUND: Acromioclavicular (AC) joint (ACJ) pathology is a common cause of shoulder dysfunction, and treatment recommendations vary. When the efficacy of treatment is evaluated, the ability to measure outcomes specific to the population is essential. The aim of the current research was to develop and validate a specific ACJ questionnaire. METHODS: Items for the "Specific AC Score" (SACS) were generated through the use of an expert panel, existing questionnaires, and patient feedback. Preliminary data analysis identified redundancy of items resulting in the questionnaire being refined. The final SACS was evaluated in 125 patients requiring surgical intervention of the ACJ. Internal consistency (the Cronbach α and corrected item-total correlation), content validity, criterion validity, responsiveness, and test-retest reliability (intraclass correlation coefficient) were examined and compared with the Shoulder Pain and Disability Index, Oxford Shoulder Score, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. The minimum detectable change score was calculated. RESULTS: The Cronbach α for the total scale preoperatively and postoperatively was high (preoperatively = 0.91, postoperatively = 0.93). All 3 domains (Pain, Function, Quality of Life) demonstrated acceptable internal consistency (α > 0.70), and the correlation between items in each domain was satisfactory. The responsiveness was excellent (effect size, -2.32; standard response mean, -1.85) and was higher than the other general shoulder questionnaires. There were no relevant floor or ceiling effects. Reliability was high (intraclass correlation coefficient, 0.89) and the minimum detectable change was 6.5 points. DISCUSSION: This new ACJ-specific questionnaire has been robustly developed, has good measurement properties, and has excellent responsiveness. The SACS is recommended for measuring outcomes in ACJ patients.

The effects of a conservative rehabilitation program for multidirectional instability of the shoulder.

BACKGROUND: Conservative management is commonly recommended as the first-line treatment for multidirectional instability (MDI) of the shoulder. Despite this, the evidence for efficacy of treatment is limited, and until recently, guidance for clinicians on conservative rehabilitation programs has been inadequate. This study evaluated the effectiveness of a physiotherapy-led exercise program for participants with MDI. METHODS: In a single-group study design, 43 participants (16 male, 27 female; mean age, 19.8 years, standard deviation, 4.9 years) diagnosed with MDI undertook a 12-week exercise program. Primary outcome measures were the Melbourne Instability Shoulder Score, Western Ontario Shoulder Instability Index, and Oxford Shoulder Instability Score. Secondary outcomes were strength and scapular position. All measures were taken at baseline and repeated at the conclusion of the program. Test differences before and after rehabilitation were evaluated with dependent t tests and single-group effect size calculations (standardized mean difference [SMD]) to provide a measure of the magnitude of the difference. RESULTS: Large effects were found between pre- and postrehabilitation scores on all functional instability questionnaires, with the Western Ontario Shoulder Instability Index demonstrating the largest effect (SMD, -3.04). Scapular upward rotation improved significantly in the early ranges of abduction (0°-60°), with moderate to large effects (SMDs, 0.54-0.95). All strength measures significantly improved, with large differences identified (SMDs, 0.69-2.08). CONCLUSION: The identified improvement in functional status, shoulder muscle strength, and scapular positioning after rehabilitation allows greater confidence in the value of conservative management of MDI and informs further research by way of clinical trials in the area.

Comparison of 2 Exercise Rehabilitation Programs for Multidirectional Instability of the Glenohumeral Joint: A Randomized Controlled Trial.

BACKGROUND: The recommended initial treatment for multidirectional instability (MDI) of the shoulder is a rehabilitation program, yet there is very low-quality evidence to support this approach. Purpose/Hypothesis: The purpose was to compare the Watson MDI program and Rockwood Instability program among patients with nontraumatic, nonstructural MDI. The hypothesis was that the Watson MDI program would produce clinically and statistically superior outcomes over the Rockwood Instability program. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Forty-one participants with MDI were randomly allocated to the Watson MDI or Rockwood Instability program. Participants attended 12 weekly physiotherapy sessions for exercise prescription. Outcomes were assessed at baseline and 6, 12, and 24 weeks after randomization. Primary outcomes were the Melbourne Instability Shoulder Score (MISS) and the Western Ontario Shoulder Index (WOSI). Secondary outcomes included the Orebro Musculoskeletal Pain Questionnaire, pain, muscle strength, scapular upward rotation, scapular coordinates, global rating of change, satisfaction scales, limiting angle in abduction range, limiting factor in abduction range, and incidence of dislocation. Primary analysis was by intention to treat based on linear mixed models. RESULTS: Between-group differences showed significant effects favoring the Watson program for the WOSI (effect size [ES], 11.1; 95% CI, 1.9-20.2; P = .018) and for the limiting factor in abduction (ES, 0.1; 95% CI, 0.0-1.6; P = .023) at 12 weeks, and for the WOSI (ES, 12.6; 95% CI, 3.4-21.9; P =. 008), MISS (ES, 15.4; 95% CI, 5.9-24.8; P = .002), and pain (ES, -2.0; CI: -2.3 to -0.7, P = .003) at 24 weeks. CONCLUSION: For people with MDI, 12 sessions of the Watson MDI program were more effective than the Rockwood program at 12- and 24-week follow-up. Registration: ACTRN12613001240730 (Australian New Zealand Clinical Trials Registry).

The treatment of multidirectional instability of the shoulder with a rehabilitation programme: Part 2.

BACKGROUND: The most commonly recommended initial treatment for multidirectional instability is a rehabilitation program. Although there is evidence to support the effect of conservative management on this condition, the published literature provides little information on the exercise parameters of such programs. METHODS: This paper is the second part of a two-part series that outlines a six-stage rehabilitation program for multidirectional instability with a focus on scapula control and exercise drills into functional positions. This paper outlines stages 3 to 6 of this rehabilitation program. RESULTS AND CONCLUSIONS: This clinical protocol is currently being tested for efficacy as part of a randomized controlled trial (Australian New Zealand Clinical Trials Registry #ACTRN12613001240730). The information in this paper and additional online supplementary files will provide therapists with adequate detail to replicate the rehabilitation program in the clinical setting.

A comprehensive rehabilitation program for posterior instability of the shoulder.

Posterior shoulder instability is recognised as being less prevalent than anterior instability, however the diagnosis of this pathology is easily overlooked or missed and this may contribute to an underestimation of prevalence. Recently, there has been increasing recognition of this condition and consequently a greater requirement for knowledge of diagnostic procedures and treatment directions. Currently there is limited research into the conservative management of posterior instability, although it is recommended as first-line treatment prior to surgical review, particularly in those with an atraumatic instability mechanism. The aim of this paper is to outline a comprehensive rehabilitation program for the conservative management of posterior instability with a focus on scapular and humeral head control. The information provided includes extensive written information, flowcharts, figures and a table of management parameters that will provide therapists with adequate detail to replicate the program in the clinical setting.

Latissimus Dorsi and Teres Major Tendon Avulsions in Cricketers: A Case Series and Literature Review.

INTRODUCTION: Acute latissimus dorsi tendon injuries are uncommon, having not previously been described in cricketers. The leg spinner's stock ball bowling technique and the fast bowler's back-of-the-hand slow ball, which is used much more widely in T20 cricket, produce a significant eccentric contraction load on the latissimus dorsi muscle. METHODOLOGY: A retrospective review of a case series of acute latissimus dorsi tendon injuries in 3 elite cricketers (2 fast bowlers and a leg-spin bowler). We compare the outcomes using patient-rated scales and objective strength testing. Two patients underwent operative repair and had excellent outcomes. One of the nonoperatively managed patients had mild ongoing symptoms at 7 months. DISCUSSION: An associated injury to teres major did not affect the outcome of this injury. Operative repair is a viable alternative and may produce better outcomes in cricketers. CONCLUSION: The short T20 form of cricket has lead to an increase in the number of back-of-the-hand slow balls, a risk factor for Latissimus injury, whereas leg-spin bowling is another risk.

The treatment of multidirectional instability of the shoulder with a rehabilitation program: Part 1.

BACKGROUND: The most commonly recommended initial treatment for multidirectional instability is a rehabilitation program. Although there is evidence to support the effect of conservative management on this condition, the published literature provides little information on the exercise parameters of such programs. In addition, current published rehabilitation programs for multidirectional instability do not focus on scapula stability or exercise drills into functional and sports-specific positions, which are often important aspects to consider in this patient population. METHODS: The aim of this paper (Part 1) is to outline the first two stages of a six-stage rehabilitation program for the conservative management of multidirectional instability with a focus on scapula control and exercise drills into functional positions. RESULTS AND CONCLUSIONS: This clinical protocol is currently being tested for efficacy as part of a randomized controlled trial (Australian New Zealand Clinical Trials Registry #ACTRN12613001240730). The information in this paper and additional online supplementary files will provide therapists with adequate detail to replicate the rehabilitation program in the clinical setting.

Effect of exercise-based management on multidirectional instability of the glenohumeral joint: a pilot randomised controlled trial protocol.

INTRODUCTION: The most commonly recommended treatment for multidirectional instability (MDI) of the shoulder is exercise. Despite this recommendation, there is limited evidence to support the effectiveness of exercise. The aim of this paper is to describe a pilot randomised controlled trial comparing the effectiveness of 2 exercise programmes on outcomes of participants with MDI. METHODS AND ANALYSIS: Consenting participants between 12 and 35 years, with non-traumatic MDI will be randomly allocated to participate in either the Rockwood Instability programme or the Watson MDI programme. Both programmes involve 1 consultation per week for 12 weeks with a physiotherapist to prescribe and progress a home exercise programme. Outcomes will be assessed at baseline, 6, 12, 24 and 52 weeks. Primary outcome measures include the Melbourne Instability Shoulder Score and Western Ontario Shoulder Index. Secondary outcomes include scapular coordinates, scapular upward rotation angles, muscle strength, symptomatic onset, limiting factor and angle of limiting factor in abduction range, incidence of complete glenohumeral joint dislocation, global rating of change, satisfaction scores, the Orebro Musculoskeletal Pain Questionnaire, adverse events and compliance with the home exercise programme. Data will be analysed on intention-to-treat principles and a per protocol basis. DISCUSSION: This trial will evaluate whether there are differences in outcomes between the Rockwood and the Watson MDI programmes for participants with MDI. ETHICS AND DISSEMINATION: Participant confidentiality will be maintained with publication of results. Ethics approval: Faculty of Health Sciences (FHEC12/201). TRIAL REGISTRATION NUMBER: ACTRN12613001240730; Pre-results.

The variable roles of the upper and lower subscapularis during shoulder motion.

BACKGROUND: The varied roles of the subscapularis muscle as an internal rotator of the humerus, a shoulder abductor, a humeral head depressor and an anterior stabiliser may be a result of differing innervation and lines of torque between its superior and inferior components. The aims of the study were to investigate the differences in the level of muscle activation between the upper and lower subscapularis during abduction, flexion, internal and external rotation movements, and temporal characteristics during abduction and flexion. METHODS: Intramuscular electrodes recorded electromyographic muscle activity from the upper and lower subscapularis muscles of the dominant throwing arm of twenty-four normal subjects. Participants completed ten repetitions of four shoulder movements - abduction, flexion, internal rotation and external rotation. Muscle activity was expressed as a percentage of maximum voluntary isometric contraction. FINDINGS: The lower subscapularis was found to activate at a higher level than the subscapularis during abduction, flexion and external rotation movements and this was significant during concentric and eccentric phases of abduction and flexion (<0.001). During internal rotation, upper subscapularis muscle activity mirrored that of lower subscapularis, with a mean difference of 1.14%. Neither upper nor lower subscapularis had onset data commencing prior to the abduction movement; however upper subscapularis activated significantly later than lower subscapularis (P=0.018). INTERPRETATION: The lower subscapularis has significantly higher muscle activity during shoulder elevation and this might reflect its greater role as a humeral head depressor and anterior stabiliser.

Modifying a shrug exercise can facilitate the upward rotator muscles of the scapula.

BACKGROUND: Scapular dyskinesis, characterised by drooping scapulae and reduced upward rotation, has been implicated in the presentation of a number of shoulder disorders. Traditionally, in shoulder rehabilitation programmes, the shrug exercise has been prescribed to facilitate upward rotation of the scapula by strengthening the upper trapezius muscle. The aim of this research was to compare muscle activation levels during the standard shrug and the upward rotation shrug in a normal and pathological population. METHODS: Surface electrodes recorded electromyographical activity from upper trapezius, middle trapezius, lower trapezius and serratus anterior muscles in 23 normal participants and 14 participants with multi-directional shoulder instability. Participants completed 10 trials of the standard shrug exercise at 0° of shoulder abduction and the upward rotation shrug exercise at 30° of shoulder abduction in the coronal plane. Muscle activity was expressed as a percentage of maximum voluntary isometric contraction. FINDINGS: The four muscles tested performed at a higher intensity during the modified shrug than the standard shrug. Upper trapezius and lower trapezius activity was significantly greater (P < 0.05) in both populations. Though for middle trapezius and serratus anterior muscles, the modified shrug was statistically significant only in the normal population, P = 0.031 and P = <0.001 respectively. INTERPRETATION: The upward rotation shrug is a more effective exercise for eliciting muscle activity of the upper and lower trapezius than the standard shrug in a normal and multi-directional instability population. Clinically, the upward rotation shrug might be useful to address scapular dyskinesis involving drooping shoulders and reduced scapula upward rotation.

Hydrodilatation (distension arthrography): a long-term clinical outcome series.

OBJECTIVES: To describe and compare the medium to long-term effectiveness of hydrodilatation and post-hydrodilatation physiotherapy in patients with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. METHODS: Patients with primary and secondary glenohumeral contractures associated with rotator cuff pathology were recruited into a 2-year study. They all underwent hydrodilatation, followed by a structured physiotherapy programme. Patients were assessed at baseline, 3 days, 1 week, 3 months, 1 year and 2 years after hydrodilatation with primary outcome measures (Shoulder Pain and Disability Index, Shoulder Disability Index and percentage rating of "normal" function; SD%) and secondary outcome measures (range of shoulder abduction, external rotation and hand behind back). Comparisons in recovery were made between the primary and secondary glenohumeral contracture groups at all timeframes and for all outcome measures. RESULTS: A total of 53 patients (23 with primary and 30 with secondary glenohumeral contractures) were recruited into the study. At the 2-year follow-up, 12 patients dropped out from the study. At baseline, the two contracture groups were similar with respect to their demographic and physical characteristics. The two groups of patients recovered in a similar fashion over the 2-year follow-up period. A significant improvement was observed in all outcomes measures over this period (p<0.01), so that both function and range of movement increased. The rate of improvement was dependent on the outcome measure that was used. CONCLUSIONS: Hydrodilatation and physiotherapy increase shoulder motion in individuals with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. This benefit continues to improve or is maintained in the long term, up to 2 years after hydrodilatation.