William R. Beach

A Review of the Special Tests Associated with Shoulder Examination Part I: The Rotator Cuff Tests

Careful examination of the shoulder is an essential component in forming a diagnosis of problems in this area. A number of tests have been described that are claimed to improve diagnostic accuracy by specifically examining one component of the shoulder complex. Many of these tests are eponymous, and there is confusion about not only how to perform them but also what conclusion to draw from the results. This article attempts to clarify the tests used to examine the rotator cuff by presenting them as described by the original authors with the additional aim of providing a source for those wishing to refresh their knowledge without the need to refer to the original source material.

Arthroscopic transglenoid multiple suture repair: 2 to 8 year results in 150 shoulders.

One hundred fifty-six arthroscopic transglenoid multiple suture repairs were performed for chronic anterior shoulder instability. In 150 shoulders (96% follow-up), the outcome with respect to recurrence of instability and the Bankart Score was determined a minimum of 2 years and a mean of 4.1 years after surgery (range, 2 to 8.2 years). During the follow-up interval, 11 shoulders (7.3%) redislocated. Fourteen other shoulders (9.3%) had at least one episode that we interpreted as recurrent subluxation. Shoulders with a Bankart lesion and younger patients had a higher probability of recurrent instability (P < .05). We concluded that this method is most effective in shoulders without a Bankart lesion and in patients older than 25 years of age (regardless of pathology).

A Review of the Special Tests Associated with Shoulder Examination: Part II: Laxity, Instability, and Superior Labral Anterior and Posterior (SLAP) Lesions

This is the second of a two-part article describing the various tests that have been used to examine the shoulder to find and treat problems in that area. Part I of this article (January/February 2003, pages 154—160) focused on tests used to examine rotator cuff abnormalities. This article attempts to clarify the tests of laxity, instability, and the superior labral anterior and posterior (SLAP) lesions by presenting them as described by the original authors, with the additional aim of providing a source for those wishing to refresh their knowledge without the need to refer to the original source material.

Safety and efficacy of US-approved viscosupplements for knee osteoarthritis: a systematic review and meta-analysis of randomized, saline-controlled trials

Background Intra-articular injection of hyaluronic acid is a common, yet controversial, therapeutic option for patients with knee osteoarthritis (OA). The purpose of this research was to determine the safety and efficacy of US-approved viscosupplements for symptomatic knee OA. Methods We searched MedLine and EMBase for randomized, sham-controlled trials evaluating safety and/or clinical efficacy of US-approved viscosupplements in patients with symptomatic knee OA. Knee pain severity and knee joint function were assessed at 4 to 13 weeks and 14 to 26 weeks. Safety outcomes included serious adverse events, treatment-related serious adverse events, patient withdrawal, and adverse event-related patient withdrawal occurring at any time during follow-up. Results A total of 29 studies representing 4,866 unique patients (active: 2,673, control: 2,193) were included. All sham-controlled trials used saline injections as a control. Viscosupplementation resulted in very large treatment effects between 4 and 26 weeks for knee pain and function compared to preinjection values, with standardized mean difference values ranging from 1.07 to 1.37 (all P<0.001). Compared to controls, standardized mean difference with viscosupplementation ranged from 0.38 to 0.43 for knee pain and 0.32 to 0.34 for knee function (all P<0.001). There were no statistically significant differences between viscosupplementation and controls for any safety outcome, with absolute risk differences of 0.7% (95% confidence interval [CI]: −0.2 to 1.5%) for serious adverse events, 0% (95% CI: −0.4 to 0.4%) for treatment-related serious adverse events, 0% (95% CI: −1.6 to 1.6%) for patient withdrawal, and 0.2% (95% CI: −0.4 to 0.8%) for adverse event-related patient withdrawal. Conclusion Intra-articular injection of US-approved viscosupplements is safe and efficacious through 26 weeks in patients with symptomatic knee OA.

Evidence-Based Medicine, Appropriate-Use Criteria, and Sports Medicine: How Best to Develop Meaningful Treatment Guidelines

We propose using appropriate-use criteria (AUC) as the methodology of choice for formulating and disseminating evidence-based medicine guidelines in sports medicine and arthroscopy. AUC provide a structured process for integrating findings from the scientific literature with clinical judgment to produce explicit criteria for determining the appropriateness of specific treatments. The use of AUC will enable surgeons to treat patients in a more consistent manner based on expert clinical consensus and evidence-based medicine. This methodology also will ensure that guidelines represent all stakeholders and available evidence.

Editorial Commentary: Where's the Respect? Physical Exam of the Shoulder

On physical examination of the shoulder, and specifically the rotator cuff, the full and empty can tests associated with weakness are the tests of choice for supraspinatus tears. However, under the huge administrative burden and in the context of the primacy of imaging mandated by regulatory agencies and/or payor, medical insurance coverage for rotator cuff repairs requires other physical examination tests and many other criteria. Moreover, some propose to reduce or even eliminate regulatory requirements mandating documentation of a history and a physical examination. It could be prudent to leave the documentation of the history and examination to the discretion of providers. Respect must be shown for the physical exam!

Vascular Risk Associated with a Posterior Approach for Posterior Cruciate Ligament Reconstruction Using the Tibial Inlay Technique (SS-67)

This study evaluated the risk to the popliteal artery associated with the tibial inlay technique in posterior cruciate ligament (PCL) reconstruction. Barium was injected into the femoral arteries of eight fresh-frozen cadaveric knees and anteroposterior (AP) radiographs were obtained. Dissection of the fascia overlying the gastrocnemius muscle, identification of the interval between the medial head of the gastrocnemius and the semimembranosus, and lateral retraction of the medial head of the gastrocnemius (the Burks and Schaffer approach) was performed. Subsequently, a bicortical screw was placed from posterior to anterior through the tibia as is performed in the tibial inlay technique. A second AP radiograph was obtained. The distance from the center of the screw to the edge of the popliteal artery was measured using digital calipers. The closest any screw came to the popliteal artery was 18.1 mm, and the average distance was 21.1 mm (21.1 +/- 4.6 mm, range: 18.1-31.7 mm). When this distance was calculated as a percentage of the tibial plateau width, the smallest value was 19.2% (24% +/- 4.9%, range: 19.2%-35.1%). A posterior approach for a tibial inlay PCL reconstruction procedure appears safe with respect to the popliteal artery.