Klaus Bak

Shoulder Strength and Range of Motion in Symptomatic and Pain-Free Elite Swimmers

To evaluate differences in shoulder strength and range of motion between painful and pain-free shoulders we examined two matched groups of athletes. Fifteen competitive swimmers were allocated to two groups. Group 1 consisted of seven swimmers with unilateral shoulder pain related to swimming (Neer and Welsh phase I to II). The control group (Group 2) consisted of eight swimmers with no present or previous history of shoulder pain. Concentric and eccentric internal rota tional torques were reduced in painful shoulders in between-group comparisons as well as in side-to-side comparisons. The decrease in internal rotational torque resulted in significantly greater concentric and eccentric external-to-internal rotational strength ratios of the painful shoulder in Group 1 swimmers compared with the controls. Furthermore, the functional ratio (ec centric external rotation:concentric internal rotation) was significantly greater in the painful shoulder in both between-group and side-to-side comparisons. Both groups of swimmers exhibited increased external range of motion and reduced internal range of motion compared with normalized data, but no between-group or side-to-side differences were detected. Our findings suggest that prevention or rehabilitation of swimmers shoulder might not solely involve strengthening of the external rotators of the shoulder joint. Attention might also be drawn toward correction of a possible deficit in internal rotational strength. Changes in shoulder range of motion seem unrelated to the occurrence of shoul der pain.

Rupture of the pectoralis major: a meta-analysis of 112 cases

Abstract Of about 150 cases reported in the literature on pectoralis major ruptures, 108 were selected as presenting enough data to be analyzed for cause, rupture site, injury mechanism, and treatment outcome. We added data on four of our own cases reported here. All patients yet reported have been men. Rupture of the PM occurs most commonly in sports during weight training, weight lifting, or wrestling when the arm is externally rotated and abducted. Most reported ruptures are complete and are located at the insertion to the humerus. Work-related injuries occur more often at the musculo-tendinous junction. The prognosis is related neither to the age of the patient nor to the location of the rupture. Surgical treatment, preferably within the first 8 weeks after the injury, has a significantly better outcome than conservative treatment or delayed repair.

Isolated partial rupture of the anterior cruciate ligament. Long-term follow-up of 56 cases.

Abstract The majority of previous studies on partial ruptures of the anterior cruciate ligament (ACL) include a relatively large proportion of knees with associated intra-articular injury or collateral ligament tear that contributes to an increase in the symptoms of instability and further deterioration of knee function. In the present study only patients with isolated, partial ruptures of the ACL were evaluated. Fifty-six patients with one injured knee were examined after a median of 5.3 (range 2.0–12.7) years using the IKDC evaluation form, Lysholm knee function score and Tegner activity score. Of the 56 knees, 6 underwent autologous reconstruction due to early progression to complete rupture. Of 34 knees evaluated for laxity, 25 had a negative Lachman test and 7 a positive (+) Lachman. In 2 knees a Lachman ++ result and a positive pivot shift were found. With instrumented laxity testing 24 knees had 2 mm or less difference in laxity compared with the contralateral uninjured knee. The largest side-to-side difference in knee laxity was 4.5 mm. Lysholm score was median 86 (range 52–100) points, and 62% had good or excellent knee function. A significant decline in activity was seen. Only 10 patients (30%) resumed their preinjury activities. We find that the majority of patients with an isolated, partial rupture of the ACL have an acceptable knee function and a stable knee after a median 5 years follow-up. There is, however, a marked reduction in activity.

Inferior Capsular Shift Procedure in Athletes with Multidirectional Instability Based on Isolated Capsular and Ligamentous Redundancy

Twenty-five athletes (26 shoulders) who underwent an inferior capsular shift procedure for multidirectional glenohumeral instability based on isolated capsular and ligamentous redundancy were evaluated at a median of 54 months (range, 25 to 113) after the operation. Twenty-one athletes (84%) returned to their preinjury activity level at a median of 5 months after surgery. Of 21 athletes involved in sports using overhead motions, 16 (76%) returned to their previous sport after the operation, and 12 (57%) were still active in this sport at the preinjury level at follow-up. According to the Rowe score, 23 shoulders (88%) were excellent or good. The University of California at Los Angeles score for 24 shoulders (92%) was excellent or good. The operations on two shoulders (8%) failed. One patient had a spontaneous redislocation, and one had recurrent subluxations. Nine contralateral shoulders had a history of significant instability; four of these had undergone Bankart repair. We concluded that athletes who have multidirectional instability based on isolated capsular and ligamentous redundancy can be successfully treated by an inferior capsular shift preserving the subscapularis tendon insertion. We found a high rate of return to demanding upper extremity sports in our patients, range of motion was restored in the majority of shoulders, and the failure rate after a median of 54 months was acceptable.

Recurrent post-traumatic anterior shoulder dislocation--open versus arthroscopic repair.

Abstract A total of 41 consecutive patients (11 women and 30 men, median age 29 (18–51) years) with unilateral, isolated, posttraumatic, recurrent anterior shoulder dislocation and a Bankart lesion were operatively repaired, either by an arthroscopic technique including a capsular plication, or by an open procedure with Mitec anchors. All the patients were followed prospectively and evaluated after a median of 36 (30–52) months follow-up by a “blind” observer. Nineteen patients in each group had excellent or good results, and one in each group was graded as fair. One patient in the arthroscopic group had a traumatic dislocation 5 months after the operation and was graded as poor. Three patients experienced subluxations postoperatively, one in the arthroscopic and two in the open group. There was no significant difference in anterior-posterior shoulder laxity measured objectively with Donjoy. The open Bankart repair group had a statistically significantly longer hospitalization (P = 0.001), a slight decrease in external range of motion, and more frequent cosmetic complaints. Apart from this, the results revealed no major differences between the two methods after a median of 36 months in this selected group of patients with longstanding problems.

Isolated total ruptures of the anterior cruciate ligament – a clinical study with long-term follow-up of 7 years

Seventy patients met our inclusion criteria in this retrospective study, all with an arthroscopic/arthrotomic‐verified isolated total anterior cruciate ligament (ACL)‐rupture and a minimum follow‐up period of 3 years and no associated lesions. Due to emigration/death, 3 patients were not available for follow‐up. Of the remaining 67, 25 patients underwent secondary ACL‐reconstruction, equivalent to a failure rate of the initial non‐operative treatment of 37%. All patients were initially treated conservatively. This left 42 patients for follow‐up – 9 answered a questionnare and 33 went through follow‐up examination after a median of 7.1 years (range 3.3–14.6) including IKDC‐evaluation form. Lysholm & Tegner score, ES‐SKA‐score, clinical examination and Stryker Laxity test. In the present study all values represent the 33 patients available for follow‐up. Soccer, handball and alpine skiing were most frequently responsible for the injury. We observed in the 33 patients a decline in median Lysholm score from 100 (90–100) pretraumatic to 86 (42–100) at follow‐up, and a decrease in median Tegner values from 7 (3–9) pretraumatic to 5 (2–7) at follow‐up. All but 2 patients demonstrated a decline in Lysholm score, and only 3 patients returned to their preinjury level. According to the ESSKA‐classification, the number of “cutting‐sports performers” declined dramatically from 24 to 2. All but one patient ascribed their decline in activity to their knee status. The Stryker‐measured AP‐translocations were significantly higher on the injured knee (7.27) compared to the healthy knee (4.80) (P<0.05). Intermittant rest pain was suffered by 63% of the patients. During the time from inclusion until follow‐up, 13 (39%) patients sustained an additional ipsilateral knee lesion, most commonly a tear of the medial meniscus. The overall outcome was expressed in a low frequency of return to unrestricted preinjury level of function, and a high level of instability complaints resulting in many secondary ACL‐reconstructions. Naturally some have adapted to their ultimate functional disability, but only through modification of activities, and the overall outcome after conservative therapy of these ACL‐ruptures was not satisfactory.

Arthroscopic repair of the bucket-handle meniscus. 10 failures in 27 stable knees followed for 3 years.

In a total of 535 meniscal lesions diagnosed by arthroscopy, 54 patients had their meniscus sutured arthroscopically. 25 cases were excluded from the study due to concomitant ligamentous injury, while 2 were lost to follow-up, leaving 27 cases of arthroscopic repair of isolated bucket-handle meniscal tears for review. 8 cases had the repaired meniscus partially resected later due to recurring symptoms. The remaining 19 cases were scored for knee function and activity after a median observation time of 36 (18-52) months. 15 of 19 patients with a supposedly healed meniscus had normal knee function, i.e., unchanged compared to preinjury levels, but a slight drop in median activity score. With 8 re-ruptures and 2 patients who stated result as poor, the 10/27 failure rate was rather high. Our results are not as good as most reported previously.

Results of reconstruction of acute ruptures of the anterior cruciate ligament with an iliotibial band autograft.

Abstract Forty patients with an acute complete tear of the anterior cruciate ligament (ACL) underwent primary reconstruction with an iliotibial band autograft after median 15 (range 0–90) days. Objective and functional evaluation was performed after median 37 (range 24–87) months by two independent observers using the International Knee Documentation Committee (IKDC) knee evaluation form, the Lysholm knee function score, and the Tegner activity score. During the observation period 5 patients sustained an ACL tear in the contralateral knee, and 1 patient (2.5%) sustained a graft rupture and underwent re-reconstruction. For the remaining 34 knees the Lysholm score at follow-up was median 100 (range 84–100, mean 97 [± 4]), all patients scoring excellent (n = 28) or good (n = 6). Three patients (9%) had more than 3 mm side-to-side difference in anteroposterior laxity. All 4 ligament failures occurred in patients operated on within the first 2 weeks after the injury. Twenty-six patients (76%) returned to the same level of activity as prior to the injury. Of 8 who dropped to a lower activity level, only one ascribed this to problems with the operated knee, meaning that 26 of 27 (96%) returned to their desired level of activity. According to the overall IKDC evaluation, 14 patients (40%) had a normal knee (A), 13 (37%) had a nearly normal knee (B), 5 (14%) had an abnormal knee (C), and 2 (9%) had a severely abnormal knee (D). Ten patients (25%) had the staples removed due to local irritation, and further 6 (15%) had local symptoms from the tibial staples. The harvest site gave 8 (20%) patients cosmetic complaints, but all graded this as slight, and 3 (8%) had slight pain during activity from the lateral muscular hernia. In selected individuals performing vigorous knee activities, autologous reconstruction of acute ACL disrupted knees with a combined internal and external iliotibial band transfer demonstrates excellent results after median 3 years. The failure rate is comparable to other techniques.

Shoulder instability Assessment of anterior-posterior translation with a knee laxity tester

We developed a simple method to measure the anterior-posterior (AP) translation of the shoulder joint: by positioning the Donjoy Knee Laxity Tester horizontally over the shoulder girdle, the AP translation was measured after applying a standardized sagittal force. Measurement of AP-translation during two tests on the same shoulder was reproducible with an intraclass correlation coefficient (ICC) of 0.996. In normal subjects the mean side difference was 0.6 mm, corresponding to a p-value of 1.00. In patients with unilateral instability AP-translation was significantly larger on the injured shoulder. Furthermore, the intraindividual differences in AP-translation were significantly larger in patients with unilateral instability than in normal subjects. Individuals with multidirectional instability had significantly higher values than any of the other groups.

Consensus Statement on Shoulder Instability

The understanding and treatment of shoulder instability comprise a rapidly evolving area of interest in orthopaedics. Evaluation methods are becoming more specific in showing the exact pathologies causing the symptoms. Magnetic resonance arthrography and arthroscopy have contributed to this development. The patient with an unstable shoulder should be thoroughly evaluated through their history and specific clinical tests of the shoulder as well as the scapulothoracic joint. Often, shoulder instability can be classified after this primary evaluation. Magnetic resonance arthrography and arthroscopy are the gold standards in soft-tissue evaluation, whereas specialized radiographic examinations and computed tomography scans are used to assess bony defects. Patients are treated according to the pathology found on preoperative or pretreatment evaluation. Multiple factors need to be considered before the treatment program is instituted, including the patients age, activity demands, associated pathology and dysfunction, soft-tissue pathology, degree of instability, direction, frequency, and etiology. Treatment can be nonoperative or arthroscopic or open repair. Soft-tissue pathology and bony defects should be addressed, and the surgeons preferred method and skills are important in choosing the right treatment for the patient. The patient should be informed about possible complications, restrictions during the treatment period, and the prognosis for the particular type of instability. To improve progress in shoulder orthopaedics, one of the most important factors can be a universal agreement on an outcome measurement tool that is well designed and validated.