Edward P. Mulligan

Structural integrity after rotator cuff repair does not correlate with patient function and pain: a meta-analysis.

BACKGROUND The correlation between the structural integrity of rotator cuff repair and the clinical outcome for the patient remains controversial. The purpose of this study was to assess the relationship between patient function and structural integrity of the rotator cuff after repair. METHODS A systematic review and a meta-analysis were conducted for Level-I and Level-II studies showing outcome measures after rotator cuff repair and an imaging assessment of the structural integrity of the repair. Data extracted included patient demographics, tear size, repair type, clinical outcome measures, and repair integrity. Statistical analysis was performed to compare outcomes in patients on the basis of the structural integrity of repair at the time of the latest follow-up. RESULTS Fourteen studies met inclusion criteria and were included in the latest analysis. Of the 861 patients who underwent rotator cuff repair with a minimum of a one-year follow-up, 674 patients (78.3%) had intact repairs at the time of latest follow-up. There was no difference in tear size between patients with intact repairs and those with retears (p = 0.866). The University of California Los Angeles shoulder score, the Constant score, and the American Shoulder and Elbow Surgeons score increased and the visual analog scale score decreased in patients regardless of the structural integrity of the repair. Patients with intact repairs had higher Constant scores by 8.93 points (p < 0.0001) and higher University of California Los Angeles shoulder scores by 2.95 points (p = 0.0004). Postoperative American Shoulder and Elbow Surgeons scores were no different in patients with intact repairs or retears (p = 0.15). Postoperative visual analog scale scores were 0.93 points lower in patients with intact repairs (p = 0.01). Patients with intact repairs had increased strength in forward elevation by 2.40 kilograms (5.29 pounds) (p < 0.00001) and had a trend toward increased strength in shoulder external rotation (p = 0.06). Although these results are significant, the differences are not clinically important on the basis of the validation of these outcome measures. CONCLUSIONS The results of this study suggest that there is not a clinically important difference in validated functional outcome scores or pain for patients who have undergone rotator cuff repair regardless of the structural integrity of the repair. Patients with intact repairs do have significantly greater strength than those with retears.

Magnetic Resonance Imaging Identification of Rotator Cuff Retears After Repair Interobserver and Intraobserver Agreement

Background: Magnetic resonance imaging (MRI) is the most commonly used imaging modality to assess the rotator cuff. Currently, there are a limited number of studies assessing the interobserver and intraobserver reliability of MRI after rotator cuff repair. Hypothesis: Fellowship-trained orthopaedic shoulder surgeons will have good inter- and intraobserver agreement with regard to features of the repaired rotator cuff (repair integrity, fat content, muscle volume, number of tendons involved, tear size, and retract) on MRI. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Seven fellowship-trained orthopaedic shoulder surgeons reviewed 31 MRI scans from 31 shoulders from patients who had previous rotator cuff repair. The scans were evaluated for the following characteristics: rotator cuff repair status (full-thickness retear vs intact repair), tear location, tendon thickness, fatty infiltration, atrophy, number of tendons involved in retear, tendon retraction, status of the long head of the biceps tendon, and bone marrow edema in the humeral head. Surgeons were asked to review images at 2 separate time points approximately 9 months apart and complete an evaluation form for each scan at each time point. Multirater kappa (κ) statistics were used to assess inter- and intraobserver reliability. Results: The interobserver agreement was highest (80%, κ = 0.60) for identifying full-thickness retears, tendon retear retraction (64%, κ = 0.45), and cysts in the greater tuberosity (72%, κ = 0.43). All other variables were found to have fair to poor agreement. The worst interobserver agreement was associated with identifying rotator cuff footprint coverage (47%, κ = −0.21) and tendon signal intensity (29%, κ = −0.01). The mean intraobserver reproducibility was also highest (77%-90%, κ = 0.71) for full-thickness retears, quality of the supraspinatus (47%-83%, κ = 0.52), tears of the long head of the biceps tendon (58%-94%, κ = 0.49), presence of bone marrow edema in the humeral head (63%-87%, κ = 0.48), cysts in the greater tuberosity (70%-83%, κ = 0.47), signal in the long head of the biceps tendon (60%-80%, κ = 0.43), and quality of the infraspinatus (37-90%, κ = 0.43). The worst intraobserver reproducibility was found in identification of the location of bone marrow edema (22%-83%, κ = −0.03). Conclusion: The results of this study indicate that there is substantial variability when evaluating MRI scans after rotator cuff repair. Intact rotator cuff repairs or full-thickness retears can be identified with moderate reliability. These findings indicate that additional imaging modalities may be needed for accurate assessment of the repaired rotator cuff.

Evaluation and management of ankle syndesmosis injuries.

BACKGROUND Ankle injuries are common in sporting activities with damage to the inferior tibiofibular ligaments being notable for their resultant disability and prolonged recovery. OBJECTIVE To provide a synopsis of the current best evidence regarding the recognition and treatment of injury to the syndesmotic ligaments of the ankle. DESIGN Structured narrative overview. METHODS Keyword search of Medline, CINAHL, and PEDro databases for studies published in English from January 1985 to July 2010. In addition, the reference lists from articles obtained were manually searched for relevant literature. SUMMARY This manuscript provides an overview of the distal tibiofibular pathologies, discusses the accuracy, limitations, and prognostic ability of clinical and radiographic examination techniques, and presents a philosophical approach to the rehabilitative management of syndesmotic injuries that integrates known biomechanical influences. CONCLUSION An appreciation for the mechanism of injury and a careful examination can distinguish these injuries from other forms of ankle instability. Proper recognition and immediate attention to the unique complexities of this joint can minimize morbidity and prevent a delayed return to sports.

Reliability and Diagnostic Accuracy of the Lachman Test Performed in a Prone Position

STUDY DESIGN Prospective, blinded, diagnostic accuracy study. OBJECTIVE To investigate the reliability and diagnostic accuracy of the Lachman test, performed in a prone position, to detect the presence of an anterior cruciate ligament (ACL) tear. Direct arthroscopic visualization and a consensus of clinical findings, including joint arthrometry and magnetic resonance imaging, were used as the reference standards. BACKGROUND An alternative position for evaluating the integrity of the ACL has been proposed as a means for examiners with smaller hands to adequately stabilize the thigh of a larger individual; however, the diagnostic accuracy of this method has not been established. METHODS Fifty-two consecutive patients with a complaint of knee pain were independently evaluated in a prone position for the status of their ACL by 2 physical therapists, before any other diagnostic assessment. The 31 men and 21 women ranged in age from 16 to 57 (mean ± SD, 34.3 ± 4.2) years and in acuity of knee injury from 21 to 365 (mean ± SD, 195 ± 130) days. RESULTS Twenty-three of 52 (44%) of the patients had a torn ACL. The agreement between examiners was 90%, with a kappa coefficient of 0.81. The sensitivity of the prone Lachman test was 70% and the specificity was 97%, resulting in a positive likelihood ratio of 20.17 and a negative likelihood ratio of 0.32. The positive predictive value was 94% and the negative predictive value was 80%. The diagnostic odds ratio was 64.0, with a number needed to diagnose of 1.5. CONCLUSION The prone Lachman test is a reliable evaluation technique that can be used to confirm the presence of an ACL tear; however, the test should not be used as the sole criterion to rule out the presence of the injury. LEVEL OF EVIDENCE Diagnosis, level 2b.

Evaluation and management of greater trochanter pain syndrome

Greater trochanteric pain syndrome is an enigmatic but common cause of lateral hip symptoms in middle-aged active women. The most common manifestation of this syndrome is a degenerative tendinopathy of the hip abductors similar to the intrinsic changes seen with rotator cuff pathology in the shoulder. There are no definitive tests to isolate the underlying pathology and palpation is a non-specific means by which to differentiate the source of the pain generator. The physical examination must comprehensively evaluate for a cluster of potential impairments and contributing factors that will need to be addressed to effectively manage the likely functional limitations and activity challenges the syndrome presents to the patient. Compressive forces through increased tension in the iliotibial band should be avoided. Intervention strategies should include education regarding postural avoidance, activity modifications, improvement of lumbopelvic control, and a patient approach to resolving hip joint restrictions and restoring the tensile capabilities of the deep rotators and abductors of the hip. A number of reliable and validated hip-specific self-report outcome tools are available to baseline a patients status and monitor their progress. Further investigations to identify the epidemiological risk factors, establish effective treatment strategies, and predict prognosis are warranted.

Factors that impact rehabilitation strategies after rotator cuff repair.

Abstract Multiple factors influence rehabilitation strategies after rotator cuff repair. These variables may also impact the overall success of the surgical intervention. Physicians and rehabilitation specialists should be aware of prognostic indicators that can provide therapeutic guidance and offer insights into eventual clinical outcomes. The success of surgical and rehabilitative interventions is often evaluated in terms of patient-reported outcome measures, return to activity, and pain. Although these factors are somewhat interdependent, each of them independently influences the final result. This article presents a comprehensive overview of the recent literature in this area to provide insight as to the short- and long-term outcomes that patients should expect based on their unique presentations. This article examines both intrinsic and extrinsic patient factors to help therapists develop customized rehabilitation programs that optimize surgical outcomes.

Hip stiffness patterns in lumbar flexion- or extension-based movement syndromes

OBJECTIVE To determine whether a relationship exists between sagittal plane hip range of motion loss and sagittal plane lumbar Movement System Impairment (MSI) categories in patients with low back pain (LBP). DESIGN Correlational study. SETTING University outpatient physical therapy clinic. PARTICIPANTS Subjects (N=40) with LBP. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Classification into a flexion- or extension-based lumbar MSI category, and bilateral passive hip flexion and extension range of motion testing. Using predefined criteria, subjects in each MSI category were subclassified into 1 of 3 hip stiffness categories: (1) a considerable loss of either flexion or extension (pattern A); (2) a considerable loss of both flexion and extension (pattern B); or (3) minimally limited flexion or extension (pattern C). RESULTS Pattern A occurred in 23 (57.5%) subjects, with the primary direction of hip motion loss agreeing with the MSI category 78.3% of the time (φ=.56; P=.007). Pattern B occurred in 10 (25%) subjects, with the primary direction of hip motion loss agreeing with the MSI category 70% of the time (φ=.47; P=.197). Pattern C occurred in 7 (17.5%) subjects, with the primary direction of hip motion limitation agreeing with the MSI category 42.9% of the time (φ=-.40; P=.290). CONCLUSIONS Considerable unidirectional hip motion loss in the sagittal plane was a common finding among subjects with LBP and yielded a strong positive relationship with the same direction MSI category. These results may inform future studies investigating whether treatment of hip stiffness patterns could improve outcomes in LBP management.

Common Fibular (Peroneal) Neuropathy as the Result of a Ganglion Cyst

The patient was a 61-year-old woman who was referred to a physical therapist with a diagnosis of right common fibular neuropathy at the fibular head involving both the deep and superficial nerve branches. Physical therapist intervention included fitting the patient with a right ankle-foot orthosis and referring the patient to her physician due to concern for a potential compressive lesion at the right proximal tibiofibular joint. Subsequent magnetic resonance imaging identified a lobulated, fluid-filled mass likely representing a ganglion cyst.

Do Magnetic Resonance Imaging Characteristics of Full-Thickness Rotator Cuff Tears Correlate With Sleep Disturbance?

Background: Many patients with rotator cuff tears suffer from nocturnal shoulder pain, resulting in sleep disturbance. Purpose: To determine whether rotator cuff tear size correlated with sleep disturbance in patients with full-thickness rotator cuff tears. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients with a diagnosis of unilateral full-thickness rotator cuff tears (diagnosed via magnetic resonance imaging [MRI]) completed the Pittsburgh Sleep Quality Index (PSQI), a visual analog scale (VAS) quantifying their shoulder pain, and the American Shoulder and Elbow Surgeons (ASES) questionnaire. Shoulder MRI scans were analyzed for anterior-posterior tear size (mm), tendon retraction (mm), Goutallier grade (0-4), number of tendons involved (1-4), muscle atrophy (none, mild, moderate, or severe), and humeral head rise (present or absent). Bivariate correlations were calculated between the MRI characteristics and baseline survey results. Results: A total of 209 patients with unilateral full-thickness rotator cuff tears were included in this study: 112 (54%) female and 97 (46%) male (mean age, 64.1 years). On average, shoulder pain had been present for 24 months. The mean PSQI score was 9.8, and the mean VAS score was 5.0. No significant correlations were found between any of the rotator cuff tear characteristics and sleep quality. Only tendon retraction had a significant correlation with pain. Conclusion: Although rotator cuff tears are frequently associated with nocturnal pain and sleep disruption, this study demonstrated that morphological characteristics of full-thickness rotator cuff tears, such as size and tendon retraction, do not correlate with sleep disturbance and have little to no correlation with pain levels.

Sleep quality in patients with rotator cuff disease

Objectives: Sleep disturbance may be an important prognostic variable driving patients to seek treatment for rotator cuff disease related shoulder pain. Currently, little is known on the influence of rotator cuff pathology on sleep. The purpose of this study was to determine which patient factors correlate with sleep disturbance in patients with atraumatic rotator cuff disease. Methods: A prospective, nonrandomized single surgeon cross-sectional cohort study was performed evaluating the effects of rotator cuff disease on sleep quality. Time-zero prior to treatment intervention outcomes data was collected including the Single Assessment Numeric Evaluation Rating (SANE), American Shoulder and Elbow Score (ASES), Pittsburgh Sleep Quality Index (PSQI), patient demographics and medical comorbidities. Statistical analysis included Pearson correlation and multiple regression analysis to determine which patient reported factors were associated with sleep quality disturbance. Results: 147 shoulders in 131 subjects 66 right 49 left 16 bilateral (66 male, 65 female) with a mean age 56.4 were enrolled. There were 92 subjects with rotator cuff tendinitis, and 34 subjects full thickness rotator cuff tears confirmed on MRI. The mean SANE was 48, VAS 4.85, ASES 52, PSQI 8.26±5.0, and 92% of subjects reported nocturnal shoulder pain. Pearson correlation coefficient determined that female sex (males -0.23, p=0.001), higher pain VAS score (+0.26, p=0.003)), depression (+0.39, p<0.0001), presence of low back pain (+0.36, p<0.0001) smoking (+0.22, p=0.01), diabetes (+0.19, p=0.03), presence of osteoarthritis (+0.19, p=0.03), and NSAID use (+0.17, p=0.05) were associated with poor sleep quality. Factors associated with worse sleep quality. Age, SANE, ASES, presence of full thickness RCT, presence of biceps pain, or cervical spine symptoms were not 1predictive and did not correlate with worse sleep quality. Conclusion: Based on our findings pain, female gender, depression, presence of low back pain, smoking, diabetes mellitus, and prior NSAID use are all factors associated with worse sleep quality in patients with rotator cuff disease. These results demonstrate that the sleep quality does not seem to correlate with severity of rotator cuff pathology.