Alberto de Castro Pochini

Management of Disorders of the Rotator Cuff: Proceedings of the ISAKOS Upper Extremity Committee Consensus Meeting

The goal of this article is to consolidate the International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine (ISAKOS) Upper Extremity Committees (UECs) current knowledge on rotator cuff disease and management, as well as highlight key unresolved issues. The rotator cuff is an anatomically complex structure important for providing glenohumeral function and stability as part of a closed chain system. Current consensus suggests rotator cuff injuries are most accurately diagnosed, at levels similar to diagnosis by magnetic resonance imaging, with a combination of cuff- and impingement-specific clinical tests. Updates in the understanding of acromion morphology, the insertional anatomy of the rotator cuff, and the role of suprascapular nerve release may require changes to current classification systems and surgical strategies. Although initial management focuses on nonoperative protocols, discussion continues on whether surgery for isolated impingement is clinically more beneficial than rehabilitation. However, clear indications have yet to be established for the use of single- versus double-row repair because evidence confirms neither is clinically efficacious than the other. Biceps tenodesis, however, in non-isolated cuff tears has proven more successful in addressing the etiology of shoulder pain and yields improved outcomes over tenotomy. Data reviewing the benefits of tendon transfers, shoulder prostheses, and mechanical scaffolds, as well as new research on the potential benefit of platelet-rich plasma, pluripotential stem cells, and gene therapies, will also be presented.

Isokinetic muscle assessment after treatment of pectoralis major muscle rupture using surgical or non-surgical procedures

INTRODUCTION: Rupture of the pectoralis major muscle appears to be increasing in athletes. However, the optimal treatment strategy has not yet been established. OBJECTIVES: To compare the isokinetic shoulder performance after surgical treatment to that after non-surgical treatment for pectoralis major muscle rupture. METHODS: We assessed 33 pectoralis major muscle ruptures (18 treated non-surgically and 15 treated surgically). Horizontal abduction and adduction as well as external and internal rotation at 60 and 120 degrees/s were tested in both upper limbs. Peak torque, total work, contralateral deficiency, and the peak torque agonist-to-antagonist ratio were measured. RESULTS: Contralateral muscular deficiency did not differ between the surgical and non-surgical treatment modalities. However, the surgical group presented twice the number of athletes with clinically acceptable contralateral deficiency (<20%) for internal rotators compared to the non-surgical group. The peak torque ratio between the external and internal rotator muscles revealed a similar deficit of the external rotation in both groups and on both sides (surgical, 61.60% and 57.80% and non-surgical, 62.06% and 54.06%, for the dominant and non-dominant sides, respectively). The peak torque ratio revealed that the horizontal adduction muscles on the injured side showed similar weakness in both groups (surgical, 86.27%; non-surgical, 98.61%). CONCLUSIONS: This study included the largest single series of athletes reported to date for this type of injury. A comparative analysis of muscular strength and balance showed no differences between the treatment modalities for pectoralis major muscle rupture. However, the number of significant clinical deficiencies was lower in the surgical group than in the non-surgical group, and both treatment modalities require greater attention to the rehabilitation process, especially for the recovery of muscle strength and balance.

Disorder of the long head of the biceps tendon

This paper focuses on biceps injuries in shoulder surgery. This topic is currently of great interest, and there has been much discussion about diagnosis, treatment and prevention. Biceps tendon pathology exists in many forms and is frequently associated with other shoulder disorders. These facts must be taken into consideration in the evaluation and treatment of patients with long head of the biceps pathology. There is much controversy about the long head of the biceps tendon (LHBT). The clinical significance to shoulder function, diagnosis and treatment are still a source of debate. The purpose of this review is to discuss the anatomy, function, pathology, clinical manifestation, physical examination, imaging and treatment of disorders of the LHBT.

Surgical versus nonsurgical treatment in first traumatic anterior dislocation of the shoulder in athletes

Anterior traumatic dislocation is a common problem faced by orthopedic surgeons. After the first episode of shoulder dislocation, a combination of lesions can lead to chronic instability. The management in treatment of young athletes after the first acute anterior shoulder dislocation is controversial. The available literature supports early surgical treatment for young male athletes engaged in highly demanding physical activities after the first episode of traumatic dislocation of the shoulder. This is because of the best functional results and lower recurrence rates obtained with this treatment in this population. However, further clinical trials of good quality comparing surgical versus nonsurgical treatment for well-defined lesions are needed, especially for categories of patients who have a lower risk of recurrence.

Strength Training Using Elastic Band Improves Muscle Power and Throwing Performance in Young Female Handball Players

CONTEXTnImbalance in shoulder-rotator muscles has been considered a risk factor for injuries in handball. Strength training programs (STPs) may play an important preventive role.nnnOBJECTIVEnTo verify the effects of an STP using elastic bands on shoulder muscles and ball-throwing speed.nnnDESIGNnRandomized and prospective controlled trial.nnnSETTINGnExercise physiology laboratory.nnnPARTICIPANTSnThirty-nine female handball players were randomly assigned to an experimental (EG, n = 21, 15.3 ± 1.1 y) or a control (CG, n = 18, 15.0 ± 0.8 y) group.nnnINTERVENTIONnThe EG performed the STP with elastic-band progressive exercises for 6 wk before regular handball training, and the CG underwent only their regular training.nnnMAIN OUTCOME MEASURESnBefore and after the STP, both groups underwent a ball-throwing-speed test and isokinetic test to assess shoulder internal- (IR) and external-rotator muscle performance.nnnRESULTSnAverage power values for IR muscles presented a significant group-vs-time interaction effect (F = 3.9, P = .05); EG presented significantly higher values after the STP (P = .03). Ball speed presented higher values in EG after the STP in standing (P = .04) and jumping (P = .03) throws. IR peak-torque values and balance in shoulder-rotator muscles presented no group-vs-time interaction effect.nnnCONCLUSIONSnSTP using elastic bands performed for 6 wk was effective to improve muscle power and ball speed for young female handball players.

Epigenetic regulation of metalloproteinases and their inhibitors in rotator cuff tears

Rotator cuff tear is a common orthopedic condition. Metalloproteinases (MMP) and their inhibitors (TIMP) seem to play a role in the development of joint injuries and in the failure of tissue healing. However, the mechanisms of regulation of gene expression in tendons are still unknown. Epigenetic mechanisms, such as DNA methylation and microRNAs regulation, are involved in the dynamic control of gene expression. Here, the mRNA expression and DNA methylation status of MMPs (MMP1, MMP2, MMP3, MMP9, MMP13, and MMP14) and TIMPs (TIMP1-3) and the expression of miR-29 family members in ruptured supraspinatus tendons were compared with non-injured tendons of individuals without this lesion. Additionally, the gene expression and methylation status at the edge of the ruptured tendon were compared with macroscopically non-injured rotator cuff tendon samples from the anterior and posterior regions of patients with tendon tears. Moreover, the possible associations between the molecular alterations and the clinical and histologic characteristics were investigated. Dysregulated expression and DNA methylation of MMP and TIMP genes were found across the rotator cuff tendon samples of patients with supraspinatus tears. These alterations were influenced at least in part by age at surgery, sex, smoking habit, tear size, and duration of symptoms. Alterations in the studied MMP and TIMP genes may contribute to the presence of microcysts, fissures, necrosis, and neovascularization in tendons and may thus be involved in the tendon healing process. In conclusion, MMPs and their inhibitors are regulated by epigenetic modifications and may play a role in rotator cuff tears.

An iliac bone stress fracture in a basketball player

The authors describe the case of an athlete from the Brazilian national men’s basketball team (sub-16) who reported pain in the right iliac region at the end of the season. Clinical and imaging exams revealed an iliac bone stress fracture. A conservative treatment of removing the load from the fracture in combination with physical therapy was chosen. The athlete improved satisfactorily and returned to the sport at the same level as prior to the injury after 14 weeks of treatment.

Exact moment of bilateral scapular fracture during skydiving captured on video.

A skydiving athlete suffered bilateral scapular fracture while jumping from the plane. A camera showed the exact moment of fracture. The injury seemed to occur during hyperextension of the arms; however, the most common mechanism of fracture is during direct trauma of the shoulder. The patient was treated by immobilisation with a sling for 3 weeks and had a good outcome. Clinical and radiographic consolidation occurred 8 weeks after the injury. The athlete returned to competitive activities after 4 months.

Modulation of isometric quadriceps strength in soccer players with transcranial direct current stimulation: a crossover study.

Abstract Vargas, VZ, Baptista, AF, Pereira, GOC, Pochini, AC, Ejnisman, B, Santos, MB, João, SMA, and Hazime, FA. Modulation of isometric quadriceps strength in soccer players with transcranial direct current stimulation: a crossover study. J Strength Cond Res 32(5): 1336–1341, 2018—The aim of this study was to evaluate the effect of transcranial direct current stimulation (tDCS) on the maximum isometric muscle contraction (MVIC) of the knee extensors in soccer players at the preprofessional level. Twenty female soccer players aged 15–17 years (mean = 16.1; SD = 0.9) with 5.2 ± 2.6 years of training were randomly divided into 2 groups to receive either active or sham tDCS in a single session (2 mA; 0.057 mA·cm−2). The MVIC of the knee extensors was evaluated in both lower limbs by manual dynamometry in 5 sets of contractions divided into 4 blocks: (a) prestimulation, (b) during tDCS, (c) 30 minutes after tDCS, and (d) 60 minutes after tDCS. After an interval of 7 days, the groups were evaluated again, and the type of initial stimulation was inverted between participants. The MVIC of the knee extensors increased significantly during active tDCS (dominant limb (DL) = 0.4; IC = 0.1–0.8 N·Kg−1), 30 minutes after active tDCS (DL = 0.9; IC 0.4–1.4 N·Kg−1), and 60 minutes after active tDCS (DL = 1.0; IC 0.3–1.6 N·Kg−1) but not for sham tDCS. Our conclusion was that tDCS temporarily increases isometric quadriceps strength in adolescent female soccer players, which may be useful for both strength training and rehabilitation.

Arthroscopic Treatment of Traumatic Posterior Shoulder Instability in Athletes

Background Unidirectional traumatic posterior shoulder instability is a specific diagnosis that differs from the more common posteroinferior or multidirectional instabilities. The treatment usually requires a surgical procedure. Methods We treated 21 shoulders in 20 patients. The average age was 29.38 years (range 20 years to 53 years). All patients were involved in recreational sports. The mean follow-up was 28 months (range 12 months to 70 months). Results The postoperative clinical evaluation was based on the Rowe score. Twenty patients were considered to demonstrate excellent results and one patient was considered to show a regular result. Twenty patients were able to return to recreational sports at the same level. One patient returned to sport at a lower level and required playing adaptations. Conclusion In our series of 21 shoulders, pain was the major symptom in 15 patients with posterior labral detachment after a traumatic event. By contrast to classic Bankart lesion, which usually results in instability, the posterior labral detachment produced pain as the major symptom in this series of patients.