Brian G. Leggin

Intrarater and interrater reliability of three isometric dynamometers in assessing shoulder strength.

The purpose of this study was to evaluate the reliability of three separate isometric strength testing devices. Seventeen (10 female, 7 male) adult volunteers with no known shoulder dysfunction participated. Each subjects internal rotation, external rotation and abduction strength was measured with the Nicholas Manual Muscle Tester (MMT), Biodex Isokinetic Dynamometer, and Isobex 2.0. Two investigators administered the test to each subject with each device. Data were analyzed with intraclass correlation coefficients (ICCs). Ranges of the intrarater intraclass correlation coefficient (3,1) values for each muscle group with each device for both testers were as follows: Nicholas MMT = .84 to .97, Biodex = .97 to .99, and Isobex 2.0 = .95 to .98. Ranges of interrater intraclass correlation coefficient values for each device and muscle group were as follows: Nicholas MMT = .79 to .94, Biodex = .93 to .96, and Isobex 2.0 = .90 to .97. Time to complete testing was shortest for Nicholas MMT, followed by Isobex 2.0, then Biodex. Measurements taken on the same day by the same therapist appear to be highly reliable for all three devices. Measurements taken over a 3-day period by two therapists appear to be highly reliable for all devices and muscle groups with the exception of Nicholas MMT abduction (.79), which was moderately reliable.

Latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears. Factors affecting outcome.

BACKGROUND The purpose of this study was to evaluate the clinical results of latissimus dorsi tendon transfer in patients with an irreparable posterosuperior rotator cuff tear to help determine which patient and anatomic factors affect clinical outcome. METHODS Fourteen patients with a latissimus dorsi tendon transfer were clinically evaluated with use of the PENN (University of Pennsylvania) shoulder score as well as with quantitative measurement of isometric muscle strength and the range of motion of both shoulders at a minimum of twenty-four months postoperatively. The anatomic results were evaluated with postoperative magnetic resonance imaging and electromyography. RESULTS Nine patients were satisfied with the outcome, had significant clinical improvement, and reported that they would have the operation again under similar circumstances. The other five patients were dissatisfied with the result and had significantly worse PENN scores, active elevation, and objective measures of strength. Eight of the nine patients with a good clinical result were male, and four of the five with a poor result were female. Patients with a good clinical result had had significantly better preoperative function in active forward flexion and active external rotation compared with the patients with a poor result. The magnetic resonance imaging demonstrated healing of the tendon to the greater tuberosity in twelve patients and equivocal healing in two. There was no significant atrophy of any of the transferred muscles. Electromyography demonstrated clear activity in the transferred latissimus muscle during humeral adduction in all fourteen patients, some electrical activity with active forward elevation in only one patient, and some electrical activity with active external rotation in six of the nine patients with a good clinical result. None of the patients with a poor clinical result demonstrated electrical activity of the transferred muscle with active forward flexion or external rotation. CONCLUSIONS Synchronous in-phase contraction of the transferred latissimus dorsi is a variable finding following the surgical treatment of irreparable posterosuperior rotator cuff tears, but when it is present it is associated with a better clinical result. Preoperative shoulder function and general strength influence the clinical result. Female patients with poor shoulder function and generalized muscle weakness prior to surgery have a greater likelihood of having a poor clinical result.

Latissimus Dorsi Tendon Transfer for Irreparable Posterosuperior Rotator Cuff Tears: Surgical Technique

BACKGROUND The purpose of this study was to evaluate the clinical results of latissimus dorsi tendon transfer in patients with an irreparable posterosuperior rotator cuff tear to help determine which patient and anatomic factors affect clinical outcome. METHODS Fourteen patients with a latissimus dorsi tendon transfer were clinically evaluated with use of the PENN (University of Pennsylvania) shoulder score as well as with quantitative measurement of isometric muscle strength and the range of motion of both shoulders at a minimum of twenty-four months postoperatively. The anatomic results were evaluated with postoperative magnetic resonance imaging and electromyography. RESULTS Nine patients were satisfied with the outcome, had significant clinical improvement, and reported that they would have the operation again under similar circumstances. The other five patients were dissatisfied with the result and had significantly worse PENN scores, active elevation, and objective measures of strength. Eight of the nine patients with a good clinical result were male, and four of the five with a poor result were female. Patients with a good clinical result had had significantly better preoperative function in active forward flexion and active external rotation compared with the patients with a poor result. The magnetic resonance imaging demonstrated healing of the tendon to the greater tuberosity in twelve patients and equivocal healing in two. There was no significant atrophy of any of the transferred muscles. Electromyography demonstrated clear activity in the transferred latissimus muscle during humeral adduction in all fourteen patients, some electrical activity with active forward elevation in only one patient, and some electrical activity with active external rotation in six of the nine patients with a good clinical result. None of the patients with a poor clinical result demonstrated electrical activity of the transferred muscle with active forward flexion or external rotation. CONCLUSIONS Synchronous in-phase contraction of the transferred latissimus dorsi is a variable finding following the surgical treatment of irreparable posterosuperior rotator cuff tears, but when it is present it is associated with a better clinical result. Preoperative shoulder function and general strength influence the clinical result. Female patients with poor shoulder function and generalized muscle weakness prior to surgery have a greater likelihood of having a poor clinical result.

Frozen Shoulder: Evidence and a Proposed Model Guiding Rehabilitation

UNLABELLED Frozen shoulder or adhesive capsulitis describes the common shoulder condition characterized by painful and limited active and passive range of motion. The etiology of frozen shoulder remains unclear; however, patients typically demonstrate a characteristic history, clinical presentation, and recovery. A classification schema is described, in which primary frozen shoulder and idiopathic adhesive capsulitis are considered identical and not associated with a systemic condition or history of injury. Secondary frozen shoulder is defined by 3 subcategories: systemic, extrinsic, and intrinsic. We also propose another classification system based on the patients irritability level (low, moderate, and high), that we believe is helpful when making clinical decisions regarding rehabilitation intervention. Nonoperative interventions include patient education, modalities, stretching exercises, joint mobilization, and corticosteroid injections. Glenohumeral intra-articular corticosteroid injections, exercise, and joint mobilization all result in improved short- and long-term outcomes. However, there is strong evidence that glenohumeral intra-articular corticosteroid injections have a significantly greater 4- to 6-week beneficial effect compared to other forms of treatment. A rehabilitation model based on evidence and intervention strategies matched with irritability levels is proposed. Exercise and manual techniques are progressed as the patients irritability reduces. Response to treatment is based on significant pain relief, improved satisfaction, and return of functional motion. Patients who do not respond or worsen should be referred for an intra-articular corticosteroid injection. Patients who have recalcitrant symptoms and disabling pain may respond to either standard or translational manipulation under anesthesia or arthroscopic release. LEVEL OF EVIDENCE Level 5.

Short-term Effects of High-Intensity Laser Therapy Versus Ultrasound Therapy in the Treatment of People With Subacromial Impingement Syndrome: A Randomized Clinical Trial

Background: Subacromial impingement syndrome (SAIS) is a painful condition resulting from the entrapment of anatomical structures between the anteroinferior corner of the acromion and the greater tuberosity of the humerus. Objective: The aim of this study was to evaluate the short-term effectiveness of high-intensity laser therapy (HILT) versus ultrasound (US) therapy in the treatment of SAIS. Design: The study was designed as a randomized clinical trial. Setting: The study was conducted in a university hospital. Patients: Seventy patients with SAIS were randomly assigned to a HILT group or a US therapy group. Intervention: Study participants received 10 treatment sessions of HILT or US therapy over a period of 2 consecutive weeks. Measurements: Outcome measures were the Constant-Murley Scale (CMS), a visual analog scale (VAS), and the Simple Shoulder Test (SST). Results: For the 70 study participants (42 women and 28 men; mean [SD] age=54.1 years [9.0]; mean [SD] VAS score at baseline=6.4 [1.7]), there were no between-group differences at baseline in VAS, CMS, and SST scores. At the end of the 2-week intervention, participants in the HILT group showed a significantly greater decrease in pain than participants in the US therapy group. Statistically significant differences in change in pain, articular movement, functionality, and muscle strength (force-generating capacity) (VAS, CMS, and SST scores) were observed after 10 treatment sessions from the baseline for participants in the HILT group compared with participants in the US therapy group. In particular, only the difference in change of VAS score between groups (1.65 points) surpassed the accepted minimal clinically important difference for this tool. Limitations: This study was limited by sample size, lack of a control or placebo group, and follow-up period. Conclusions: Participants diagnosed with SAIS showed greater reduction in pain and improvement in articular movement functionality and muscle strength of the affected shoulder after 10 treatment sessions of HILT than did participants receiving US therapy over a period of 2 consecutive weeks.

Spinal Accessory Nerve Palsy: Associated Signs and Symptoms

STUDY DESIGN Retrospective case series. BACKGROUND Spinal accessory nerve palsy (SANP) is common following neck dissection surgery and can occur with blunt or penetrating trauma to the lateral neck region and cervical stretch injuries. Early detection of SANP remains a clinical challenge and the condition is often misdiagnosed. The purpose of this case series is to describe the associated history, signs, and symptoms related to SANP and increase awareness of the scapular flip sign as a clinical sign associated with SANP. CASE SERIES DESCRIPTION: Twenty subjects (13 male, 7 female) presented with pain and decreased shoulder function following head and neck surgery or posttrauma. All patients were thoroughly examined and the scapular flip sign was assessed. All patients presented with a cluster of signs and symptoms including trapezius atrophy, shoulder girdle depression, limited active shoulder abduction to less than 90 degrees , shoulder pain, and shoulder weakness. A positive scapular flip sign was present in all cases. The middle and lower trapezius were rated as 0/5, based on manual muscle testing, indicating no identifiable muscle activation against resistance. DISCUSSION A typical history and consistent signs and symptoms were found related to SANP. A strong relationship appeared between the presence of the scapular flip sign and SANP. The suspected mechanism for the scapular flip sign is the unopposed pull of the humeral external rotators by the inactive middle and lower trapezius. Early identification of SANP can assist with the prognosis, explain persistent impairments and functional deficits, motivate appropriate diagnostic testing and interventions, and help maximize outcome. Further research to validate the scapular flip sign and establish a clinical prediction rule for the diagnosis of SANP should be performed.

RESULTS OF SURGICAL REPAIR OF FULL-THICKNESS TEARS OF THE ROTATOR CUFF

Shoulder pain is often caused by pathologic conditions of the rotator cuff. Many investigators have studied the factors that influence the outcome after rotator cuff repair. This article reviews the different factors and the various methods of reporting outcome after shoulder surgery.

The American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation following arthroscopic rotator cuff repair

This is a consensus statement on rehabilitation developed by the American Society of Shoulder and Elbow Therapists. The purpose of this statement is to aid clinical decision making during the rehabilitation of patients after arthroscopic rotator cuff repair. The overarching philosophy of rehabilitation is centered on the principle of the gradual application of controlled stresses to the healing rotator cuff repair with consideration of rotator cuff tear size, tissue quality, and patient variables. This statement describes a rehabilitation framework that includes a 2-week period of strict immobilization and a staged introduction of protected, passive range of motion during weeks 2-6 postoperatively, followed by restoration of active range of motion, and then progressive strengthening beginning at postoperative week 12. When appropriate, rehabilitation continues with a functional progression for return to athletic or demanding work activities. This document represents the first consensus rehabilitation statement developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients after arthroscopic rotator cuff repair.

Maximizing Return to Activity Post Cuff and Instability Surgery

Designing a rehabilitation program after a patient has had surgical intervention should take several factors into account: the degree and type of mechanical disruption, the type and strength of the surgical procedure, the chronicity of the problem, the strength and endurance of the rotator cuff and the scapular musculature, the flexibility of the soft tissues around the shoulder, and the patient’s anticipated level and type of activity post-rehabilitation. Postoperative guidelines which respect tissue healing timelines should be followed; at the same time, the patient should be progressed through the phases of rehabilitation only when the criteria of each phase are met.