Grant L. Jones

Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study

PURPOSE To assess the effectiveness of a specific nonoperative physical therapy program in treating atraumatic full-thickness rotator cuff tears using a multicenter prospective cohort study design. MATERIALS AND METHODS Patients with atraumatic full-thickness rotator cuff tears who consented to enroll provided data via questionnaire on demographics, symptom characteristics, comorbidities, willingness to undergo surgery, and patient-related outcome assessments (Short Form 12 score, American Shoulder and Elbow Surgeons score, Western Ontario Rotator Cuff score, Single Assessment Numeric Evaluation score, and Shoulder Activity Scale). Physicians recorded physical examination and imaging data. Patients began a physical therapy program developed from a systematic review of the literature and returned for evaluation at 6 and 12 weeks. At those visits, patients could choose 1 of 3 courses: (1) cured (no formal follow-up scheduled), (2) improved (continue therapy with scheduled reassessment in 6 weeks), or (3) no better (surgery offered). Patients were contacted by telephone at 1 and 2 years to determine whether they had undergone surgery since their last visit. A Wilcoxon signed rank test with continuity correction was used to compare initial, 6-week, and 12-week outcome scores. RESULTS The cohort consists of 452 patients. Patient-reported outcomes improved significantly at 6 and 12 weeks. Patients elected to undergo surgery less than 25% of the time. Patients who decided to have surgery generally did so between 6 and 12 weeks, and few had surgery between 3 and 24 months. CONCLUSION Nonoperative treatment using this physical therapy protocol is effective for treating atraumatic full-thickness rotator cuff tears in approximately 75% of patients followed up for 2 years.

Interobserver Agreement in the Classification of Rotator Cuff Tears Using Magnetic Resonance Imaging

Background Although magnetic resonance imaging (MRI) is a standard method of assessing the extent and features of rotator cuff disease, the authors are not aware of any studies that have assessed the interobserver agreement among orthopaedic surgeons reviewing MRI scans for rotator cuff disease. Hypothesis Fellowship-trained orthopaedic shoulder surgeons will have good interobserver agreement in predicting the more salient features of rotator cuff disease such as tear type (full thickness versus partial thickness), tear size, and number of tendons involved but only fair agreement with more complex features such as muscle volume, fat content, and the grade of partial-thickness cuff tears. Study Design Cohort study (diagnosis); Level of evidence, 3. Methods Ten fellowship-trained orthopaedic surgery shoulder specialists reviewed 27 MRI scans of 27 shoulders from patients with surgically confirmed rotator cuff disease. The ability to interpret full-thickness versus partial-thickness tears, acromion type, acromioclavicular joint spurs or signal changes, biceps lesions, size and grade of partial-thickness tears, acromiohumeral distance, number of tendons involved and amount of retraction for full-thickness tears, size of full-thickness tears, and individual muscle fatty infiltration and atrophy were assessed. Surgeons completed a standard evaluation form for each MRI scan. Interobserver agreement was determined and a kappa level was derived. Results Interobserver agreement was highest (>80%) for predicting full- versus partial-thickness tears of the rotator cuff, and for quantity of the teres minor tendon. Agreement was slightly less (>70%) for detecting signal in the acromioclavicular joint, the side of the partial-thickness tear, the number of tendons involved in a full-thickness tear, and the quantity of the subscapularis and infraspinatus muscle bellies. Agreement was less yet (60%) for detecting the presence of spurs at the acromioclavicular joint, a tear of the long head of the biceps tendon, amount of retraction of a full-thickness tear, and the quantity of the supraspinatus. The best kappa statistics were found for detecting the difference between a full- and partial-thickness rotator cuff tear (0.77), and for the number of tendons involved for full-thickness tears (0.55). Kappa for predicting the involved side of a partial-thickness tear was 0.44; for predicting the grade of a partial-thickness tear, it was −0.11. Conclusions Fellowship-trained, experienced orthopaedic surgeons had good agreement for predicting full-thickness rotator cuff tears and the number of tendons involved and moderate agreement in predicting the involved side of a partial-thickness rotator cuff tear, but poor agreement in predicting the grade of a partial-thickness tear.

Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients.

Background: Elbow tenderness and pain with resisted wrist extension are common manifestations of lateral epicondylar tendinopathy, also known as tennis elbow. Previous studies have suggested platelet-rich plasma (PRP) to be a safe and effective therapy for tennis elbow. Purpose: To evaluate the clinical value of tendon needling with PRP in patients with chronic tennis elbow compared with an active control group. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 230 patients with chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at least 3 months of symptoms and had failed conventional therapy. There were no differences in patients randomized to receive PRP (n = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the point of care and contained both concentrated platelets and leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled with or without PRP. Patients and investigators remained blinded to the treatment group throughout the study. A successful outcome was defined as 25% or greater improvement on the visual analog scale for pain. Results: Patient outcomes were followed for up to 24 weeks. At 12 weeks (n = 192), the PRP-treated patients reported an improvement of 55.1% in their pain scores compared with 47.4% in the active control group (P = .163). At 24 weeks (n = 119), the PRP-treated patients reported an improvement of 71.5% in their pain scores compared with 56.1% in the control group (P = .019). The percentage of patients reporting significant elbow tenderness at 12 weeks was 37.4% in the PRP group versus 48.4% in the control group (P = .143). Success rates for patients at 12 weeks were 75.2% in the PRP group versus 65.9% in the control group (P = .104). At 24 weeks, 29.1% of the PRP-treated patients reported significant elbow tenderness versus 54.0% in the control group (P = .009). Success rates for patients with 24 weeks of follow-up were 83.9% in the PRP group compared with 68.3% in the control group (P = .037). No significant complications occurred in either group. Conclusion: No significant differences were found at 12 weeks in this study. At 24 weeks, however, clinically meaningful improvements were found in patients treated with leukocyte-enriched PRP compared with an active control group.Methods: A total of 230 patients with chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at least 3 months of symptoms and had failed conventional therapy. There were no differences in patients randomized to receive PRP (n = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the point of care and contained both concentrated platelets and leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled with or without PRP. Patients and investigators remained blinded to the treatment group throughout the study.

Arthroscopy of the Elbow

As our understanding of the anatomy and function of the elbow joint continues to grow and technology continues to advance, our ability to correct disorders of the elbow with arthroscopic techniques will expand. Today, we are at the brink of major advances in the arthroscopic evaluation and treatment of elbow ailments. Many open surgical procedures currently being performed will undoubtedly be adapted for an arthroscopic approach, as we are already seeing in the treatment of radiocapitellar arthrosis, tennis elbow, arthrofibrosis, and ulnohumeral arthroplasty. Elbow procedures, such as ligamentous tightening, fracture treatment with bioabsorbable devices, and biologic joint replacement will be commonly performed in the future with the aid of the arthroscope. Although elbow arthroscopy is technically demanding, it is a highly effective surgical technique in treating many intra-articular disorders with minimal morbidity. Most of the complications associated with elbow arthroscopy can be avoided by adhering to strict and proper surgical technique. Successful elbow arthroscopy requires a thorough understanding of local gross and arthroscopic anatomy. To maintain proper orientation at all times, the skin should be properly marked before starting the procedure. The joint should be kept distended during initiation of portals to move the neurovascular structures away from the arthroscopic instruments. Nonvented cannulas with blunt trocars should be used to allow for safe passage of instruments and to avoid multiple capsular punctures. Finally, the elbow should remain flexed to 90 deg during most of the procedure, thus keeping the neurovascular structures in the antecubital fossa relaxed. If these techniques are followed, the surgical morbidity should remain low, and surgeon and patient will find elbow arthroscopy tremendously effective.

Interobserver agreement in the classification of rotator cuff tears

Background Six classification systems have been proposed for describing rotator cuff tears designed to help understand their natural history and make treatment decisions. Purpose To assess the interobserver variation for these classification systems and identify the method with the best interob-server agreement. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods Six rotator cuff tear classification systems were identified in a literature search. The components of these systems included partial-thickness rotator cuff tears and classification by size, shape, configuration, number of tendons involved, and by extent, topography, and nature of the biceps. Twelve fellowship-trained orthopaedic surgeons who each perform at least 30 rotator cuff repairs per year reviewed arthroscopy videos from 30 patients with a random assortment of rotator cuff tears and classified them by the 6 classification systems. Interobserver variation was determined by a kappa analysis. Results Interobserver agreement was high when distinguishing between full-thickness and partial-thickness tears (0.95, [UNKNOWN]=0.85). The investigators agreed on the side (articular vs bursal) of involvement for partial-thickness tears (observed agreement 0.92, [UNKNOWN]= 0.85) but could not agree when classifying the depth of the partial-thickness tear (observed agreement 0.49, [UNKNOWN]= 0.19). The best agreement for full-thickness tears was seen when the tear was classified by topography (degree of retraction) in the frontal plane (observed agreement 0.70, [UNKNOWN]= 0.54). Conclusion With the exception of distinguishing partial-thickness from full-thickness rotator cuff tears and identifying the side (articular vs bursal) of involvement with partial-thickness tears, currently described rotator cuff classification systems have little interobserver agreement among experienced shoulder surgeons. Researchers should consider describing full-thickness rotator cuff tears by topography (degree of retraction) in the frontal plane.

Comparison of various imaging techniques to quantify glenoid bone loss in shoulder instability

INTRODUCTION The purpose of this study was to determine the most accurate imaging modality to quantify glenoid bone loss in recurrent anterior shoulder instability. This will allow the best preoperative prediction for patients needing a bone graft. MATERIALS AND METHODS Seven fresh frozen shoulder cadavers were imaged with radiographs, magnetic resonance imaging (MRI), computed tomography (CT), and 3-dimensional CT (3-D CT). Native shoulders were imaged, and 3 sequential anterior-inferior glenoid defects were created, measured, and reimaged. Defect sizes were <12.5%, 12.5% to 27%, and >27%. Four blinded evaluators (2 musculoskeletal radiologists, 2 shoulder fellowship-trained surgeons) reviewed the 112 image sets and estimated the percentage of glenoid bone loss. Images were scrambled and re-reviewed by the same observers 2 months later to determine intraobserver reliability. RESULTS Pearson correlation coefficients between predicted vs true bone loss across all 4 raters were 0.875 (3-D CT), 0.831 (CT), 0.693 (MRI), and 0.457 (x-ray imaging). Prediction errors (PE) were (mean ± SD in percentages) 3-D CT (-3.3 ± -6.6), CT (-3.7 ± -8.0), MRI (-2.75 ± -10.6), and x-ray images (-6.9 ± -13.1). Mean PE values were not significantly different among 3-D CT, CT, and MRI; however, the PE SDs were similar among the 4 evaluators for 3-D CT and lower than all other imaging techniques. Prediction based on x-ray images had the largest PE and SD. Covariance parameters revealed large variances for shoulders for MRI and x-ray imaging. The intraobserver intraclass correlation coefficients were 0.947 (3-D CT), 0.927 (CT), 0.837 (MRI), and 0.726 (x-ray image). CONCLUSIONS The most accurate imaging modality in predicting glenoid bone loss among the 4 blinded independent evaluators was 3-D CT.

Biomechanical Comparison of Coracoclavicular Reconstructive Techniques

Background: Acromioclavicular joint dislocations are common orthopaedic injuries. Numerous operative techniques have been described, but the gold standard has yet to be defined. The goal of fixation is to create a stiff and strong reconstruction of the coracoclavicular ligaments to provide optimal stability. The modified Weaver-Dunn is the traditional surgical procedure. However, due to the high rate of recurrent instability with this technique, a shift toward a more anatomic repair has occurred. Purpose: To evaluate the biomechanical performance of multiple types of coracoclavicular ligament reconstruction. Study Design: Controlled laboratory study. Methods: Thirty fresh-frozen human cadaveric shoulders were assigned to 1 of 5 reconstruction groups or a control group: modified Weaver-Dunn, nonanatomic allograft, anatomic allograft, anatomic suture, and GraftRope. A type III acromioclavicular joint dislocation was simulated in all specimens. The 5 techniques were completed, and a cyclic preload and a load-to-failure protocol were performed. Results: The control had an average load to failure of 1330.6 ± 447.0 N. Compared with all techniques, the anatomic allograft had the highest load to failure, 948 ± 148 N. It had a significantly higher load to failure than the modified Weaver-Dunn (523.2 ± 98.6 N, P = .001), the anatomic suture (578.2 ± 195.3 N, P = .01), the nonanatomic allograft (591.2 ± 65.6 N, P = .003), and the GraftRope (646 ± 167.4, P = .016). No significant difference in load to failure was found between the remaining techniques. Conclusion: The anatomic allograft reconstruction has superior initial biomechanical properties compared with the modified Weaver-Dunn, nonanatomic allograft, anatomic suture, and GraftRope techniques. Clinical Relevance: Anatomic reconstruction of the coracoclavicular ligaments with allograft may provide a stronger biological solution for acromioclavicular joint dislocations. This reconstruction may minimize recurrent subluxation and pain and permit earlier rehabilitation when compared with current techniques.

Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear.

BACKGROUND For many orthopaedic disorders, symptoms correlate with disease severity. The objective of this study was to determine if pain level is related to the severity of rotator cuff disorders. METHODS A cohort of 393 subjects with an atraumatic symptomatic full-thickness rotator-cuff tear treated with physical therapy was studied. Baseline pretreatment data were used to examine the relationship between the severity of rotator cuff disease and pain. Disease severity was determined by evaluating tear size, retraction, superior humeral head migration, and rotator cuff muscle atrophy. Pain was measured on the 10-point visual analog scale (VAS) in the patient-reported American Shoulder and Elbow Surgeons (ASES) score. A linear multiple regression model was constructed with use of the continuous VAS score as the dependent variable and measures of rotator cuff tear severity and other nonanatomic patient factors as the independent variables. Forty-eight percent of the patients were female, and the median age was sixty-one years. The dominant shoulder was involved in 69% of the patients. The duration of symptoms was less than one month for 8% of the patients, one to three months for 22%, four to six months for 20%, seven to twelve months for 15%, and more than a year for 36%. The tear involved only the supraspinatus in 72% of the patients; the supraspinatus and infraspinatus, with or without the teres minor, in 21%; and only the subscapularis in 7%. Humeral head migration was noted in 16%. Tendon retraction was minimal in 48%, midhumeral in 34%, glenohumeral in 13%, and to the glenoid in 5%. The median baseline VAS pain score was 4.4. RESULTS Multivariable modeling, controlling for other baseline factors, identified increased comorbidities (p = 0.002), lower education level (p = 0.004), and race (p = 0.041) as the only significant factors associated with pain on presentation. No measure of rotator cuff tear severity correlated with pain (p > 0.25). CONCLUSIONS Anatomic features defining the severity of atraumatic rotator cuff tears are not associated with the pain level. Factors associated with pain are comorbidities, lower education level, and race. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Pain and Function in Patients With Symptomatic, Atraumatic Full-Thickness Rotator Cuff Tears A Time-Zero Analysis of a Prospective Patient Cohort Enrolled in a Structured Physical Therapy Program

Background: Although the prevalence of full-thickness rotator cuff tears increases with age, many patients are asymptomatic and may not require surgical repair. The factors associated with pain and loss of function in patients with rotator cuff tears are not well defined. Purpose: To determine which factors correlate with pain and loss of function in patients with symptomatic, atraumatic full-thickness rotator cuff tears who are enrolled in a structured physical therapy program. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A multicenter group enrolled patients with symptomatic, atraumatic rotator cuff tears in a prospective, nonrandomized cohort study evaluating the effects of a structured physical therapy program. Time-zero patient data were reviewed to test which factors correlated with Western Ontario Rotator Cuff (WORC) index and American Shoulder and Elbow Surgeons (ASES) scores. Results: A total of 389 patients were enrolled. Mean ASES score was 53.9; mean WORC score was 46.9. The following variables were associated with higher WORC and ASES scores: female sex (P = .001), education level (higher education, higher score; P < .001), active abduction (degrees; P = .021), and strength in forward elevation (P = .002) and abduction (P = .007). The following variables were associated with lower WORC and ASES scores: male sex (P = .001), atrophy of the supraspinatus (P = .04) and infraspinatus (P = .003), and presence of scapulothoracic dyskinesia (P < .001). Tear size was not a significant predictor (WORC) unless comparing isolated supraspinatus tears to supraspinatus, infraspinatus, and subscapularis tears (P = .004). Age, tear retraction, duration of symptoms, and humeral head migration were not statistically significant. Conclusion: Nonsurgically modifiable factors, such as scapulothoracic dyskinesia, active abduction, and strength in forward elevation and abduction, were identified that could be addressed nonoperatively with therapy. Therefore, physical therapy for patients with symptomatic rotator cuff tears should target these modifiable factors associated with pain and loss of function.

Adhesive capsulitis of the shoulder: a systematic review of the effectiveness of intra-articular corticosteroid injections.

Primary adhesive capsulitis, or “frozen shoulder,” is a common condition encountered in the outpatient orthopaedic clinic. It is characterized by the spontaneous onset of shoulder pain and global limitation of both active and passive shoulder motion. This condition was first described by Codman in 19341 and was most recently defined by the American Academy of Orthopaedic Surgeons as “a condition of varying severity characterized by the gradual development of global limitation of active and passive shoulder motion where radiographic findings other than osteopenia are absent.”2 This condition has a prevalence of 2% to 5% in the outpatient setting, but in patients with insulin-dependent diabetes mellitus, the prevalence increases to about 30%3. The pathogenesis of this condition remains unclear, although factors associated with it include female sex, trauma, an age of more than forty years, diabetes, prolonged immobilization, thyroid disease, stroke, myocardial infarction, and the presence of autoimmune disease4. Adhesive capsulitis is commonly described as passing through three stages3-5. Stage 1 is referred to as “freezing” and consists of increasing pain and stiffness lasting for period of as long as nine months. Stage 2 is termed “frozen” and involves a steady state for a period lasting between four and twenty months. Finally, Stage 3 is termed “thawing,” which is a period of spontaneous recovery lasting anywhere from five to twenty-six months. This diagnosis is made clinically on the basis of pain and limitation of both passive and active range of shoulder motion. Although typically described as a self-limiting disease process6, the natural history of adhesive capsulitis is not completely known, and recent studies have shown that it can lead to longer-term disability over the course of several years7-10. Common nonoperative interventions used for the treatment …